U.S. patent number 10,329,621 [Application Number 14/181,121] was granted by the patent office on 2019-06-25 for dna methylation markers and methods of use.
This patent grant is currently assigned to The Johns Hopkins University. The grantee listed for this patent is The Johns Hopkins University. Invention is credited to Stephen B. Baylin, Malcolm V. Brock, James G. Herman.
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United States Patent |
10,329,621 |
Brock , et al. |
June 25, 2019 |
DNA methylation markers and methods of use
Abstract
The present invention provides methods for identifying
metastases by detecting nucleic acid hypermethylation of one or
more genes in one or more samples, and in particular in the lymph
nodes. The invention further relates to DNA methylation as a
predictor of disease recurrence and patient prognosis, specifically
in the field of cancer biology.
Inventors: |
Brock; Malcolm V. (Owings
Mills, MD), Baylin; Stephen B. (Baltimore, MD), Herman;
James G. (Lutherville, MD) |
Applicant: |
Name |
City |
State |
Country |
Type |
The Johns Hopkins University |
Baltimore |
MD |
US |
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Assignee: |
The Johns Hopkins University
(Baltimore, MD)
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Family
ID: |
39430374 |
Appl.
No.: |
14/181,121 |
Filed: |
February 14, 2014 |
Prior Publication Data
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Document
Identifier |
Publication Date |
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US 20150031022 A1 |
Jan 29, 2015 |
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Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
Issue Date |
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12515735 |
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PCT/US2007/024308 |
Nov 20, 2007 |
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60860196 |
Nov 20, 2006 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
C12Q
1/6886 (20130101); A61P 35/00 (20180101); C12Q
2600/16 (20130101); C12Q 2600/112 (20130101); C12Q
2600/118 (20130101); C12Q 2600/154 (20130101) |
Current International
Class: |
C07H
21/04 (20060101); C12Q 1/6886 (20180101); C12Q
1/68 (20180101) |
References Cited
[Referenced By]
U.S. Patent Documents
Foreign Patent Documents
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2002-044331 |
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Jun 2002 |
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WO |
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2005/042713 |
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May 2005 |
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WO |
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Other References
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.
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examiner .
Feng (PNAS 2010 vol. 107 No. 19 pp. 8689-8694). cited by examiner
.
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by examiner .
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examiner .
Momparler (Lung Cancer 34 2001 S111-S115). cited by examiner .
Tang Moying et al: "Wnt signaling promoter hypermethylation
distinguishes lung primary adenocarcinomas from colorectal
metastasis to the lung" vol. 119, No. 11, Dec. 2006 (Dec. 2006),
pp. 2603-2606. cited by applicant .
Kohonen-Corish Maija R J et al: "Promoter hypermethylation of the
0-6-methylguanine DNA methyltransferase gene and microsatellite
instability in metastatic melanoma" Journal of Investigative
Dermatology, vol. 126, No. 1, Jan. 2006 (Jan. 2006), pp. 167-171.
cited by applicant .
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in primary and metastatic colorectal cancers" Neoplasia (New York),
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associated with tumor progression in primary nonsmall cell lung
carcinoma." Cancer. Nov. 1, 2005;104(9):1825-33. cited by applicant
.
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the CDH13 (H-cadherin) gene in breast and lung carcinomas." Cancer
Res. Jun. 1, 2001;61(11):4556-60. cited by applicant .
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patients: biological and clinical implications", Carcinogenesis,
vol. 24, No. 12, Jan. 1, 2003, pp. 1897-1907. cited by applicant
.
Nakata Shoji et al. "The methylation status and protein expression
of CDH1, p16(INK4A), and fragile histidine triad in nonsmall cell
lung carcinoma--Epigenetic silencing, clinical features, and
prognostic signficance", Cancer, vol. 106, No. 10, May 2006, pp.
2190-2199. cited by applicant .
Harden Susan V. et al. "Gene promoter hypermethylation in tumors
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Research: An Official Journal of the American Association for
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2003, pp. 1370-1375. cited by applicant .
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multiple genes in non-small cell lung cancers", Cancer Research,
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1, 2001, pp. 249-255. cited by applicant .
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of tumor suppressor genes in serum DNA from non-small cell lung
patients", Cancer Research, American Association for Cancer
Research, US, vol. 59, Jan. 1, 1999, pp. 67-70. cited by applicant
.
Feng, Suhua et al. Conservation and divergence of methylation
patterning in plants and animals. PNAS 2010 vol. 107 No. 19, pp.
8689-8694. cited by applicant .
Toyooka, Shinichi et al. DNA methylation Profiles of Lung Tumors.
Molecular Cancer Therapeutics Nov. 2001 vol. 1 pp. 61-67. cited by
applicant .
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Primary Examiner: Goldberg; Jeanine A
Attorney, Agent or Firm: Mintz Levin Cohn Ferris Glovsky and
Popeo, P.C. Corless; Peter F.
Parent Case Text
RELATED APPLICATIONS
This application is a continuation of U.S. application Ser. No.
12/515,735, filed Jun. 30, 2010, which is the U.S. national phase,
pursuant to 35 U.S.C. .sctn. 371, of PCT international application
Ser. No. PCT/US2007/024308, filed Nov. 20, 2007, designating the
United States and published in English on May 29, 2008 as
publication WO 2008/063655 A2, which claims priority to U.S.
provisional application Ser. No. 60/860,196, filed Nov. 20, 2006.
The entire contents of the aforementioned patent applications are
incorporated herein by this reference.
Claims
What is claimed is:
1. A method for treating non-small cell lung cancer metastases in a
human subject consisting of: a) obtaining a biological sample from
a human subject, wherein the biological sample is a lung tumor
tissue sample, a regional lymph node or a mediastinal lymph node;
b) isolating genomic DNA from the biological sample; c) contacting
the isolated genomic DNA with bisulfite to transform unmethylated
cytosines in the genomic DNA to uracil; d) PCR amplifying the
transformed genomic DNA of the p16 gene encoding SEQ ID NO: 2 and
the H-cadherin gene encoding SEQ ID NO: 1 using primers consisting
of: (i) a pair of methylation primers specific for p16 and a pair
of methylation primers specific for H-cadherin genes and (ii) a
pair of unmethylated primers specific for p16 and a pair of
unmethylated primers specific for H-cadherin genes; e) detecting
methylation of genomic p16 and H-cadherin DNA; f) diagnosing
non-small cell lung cancer metastases in the human subject; and g)
administering a therapeutically effective amount of a demethylating
agent to the human_subject diagnosed as having non-small cell lung
cancer metastases, thereby treating the non-small cell lung cancer
metastases.
2. The method of claim 1, wherein the non-small cell lung cancer
metastases are micrometastases.
3. A method for treating a recurrence of a non-small cell lung
cancer (NSCLC) in a human subject consisting of: a) obtaining a
biological sample from a human subject to be treated, wherein the
biological sample is a lung tumor tissue sample, a regional lymph
node or a mediastinal lymph node; b) isolating genomic DNA from the
biological sample; c) contacting the isolated genomic DNA with
bisulfite to transform unmethylated cytosines in the genomic DNA to
uracil; d) PCR amplifying the transformed genomic DNA of the p16
gene encoding SEQ ID NO: 2 and the H-cadherin gene encoding SEQ ID
NO: 1 using primers consisting of: (i) a pair of methylation
primers specific for p16 and a pair of methylation primers specific
for H-cadherin genes and (ii) a pair of unmethylated primers
specific for p16 and a pair of unmethylated primers specific for
H-cadherin genes; e) detecting methylation of genomic p16 and
H-cadherin DNA; f) diagnosing non-small cell lung cancer metastases
in the human subject; and g) administering a therapeutically
effective amount of a demethylating agent to the human_subject
diagnosed as having non-small cell lung cancer metastases, thereby
treating the recurrence of NSCLC in the human subject.
4. A method for treating recurrence of non-small cell lung cancer
(NSCLC) metastases in a human subject consisting of: a) obtaining a
biological sample from a human subject to be treated, wherein the
biological sample is a lung tumor tissue sample, a regional lymph
node or a mediastinal lymph node; b) providing a kit having
bisulfite and methylation specific PCR primers for detecting a
hypermethylation state of a p16 gene encoding SEQ ID NO: 2 and the
H-cadherin gene encoding SEQ ID NO: 1; c) contacting the biological
sample with the bisulfite from the kit to transform unmethylated
cytosines in the genomic DNA in the biological sample to uracil; d)
PCR amplifying the transformed genomic DNA with the methylation
specific PCR primers in the kit to detect nucleic acid methylation
of the p16 gene and the H-cadherin gene in the lung tumor tissue
sample, a regional lymph node or a mediastinal lymph node in the
transformed genomic DNA; Wherein the methylation specific PCR
primers are specific for bisulfite transformed unmethylated
cytosines; e) detecting methylation of genomic p16 and H-cadherin
DNA; f) diagnosing non-small cell lung cancer metastases in the
human subject; and g) administering a therapeutically effective
amount of a demethylating agent to the human_subject diagnosed as
having non-small cell lung cancer metastases, thereby treating the
recurrence of NSCLC in the human subject.
Description
FIELD OF THE INVENTION
The present invention relates to the use of nucleic acid
methylation and methylation profiles to detect metastatic disease.
In particular, the invention relates to methods for identifying
metastases by detecting nucleic acid hypermethylation of one or
more genes in one or more samples and, in particular, in tumor
tissue and lymph nodes. The invention further relates to DNA
hypermethylation as a predictor of disease recurrence and patient
prognosis, specifically in patients suffering from cancer.
BACKGROUND OF THE INVENTION
Cancer remains one of the leading causes of death in the United
States. Clinically, a broad variety of medical approaches,
including surgery, radiation therapy and chemotherapeutic drug
therapy are currently being used in the treatment of human cancer
(see the textbook CANCER: Principles & Practice of Oncology, 2d
Edition, De Vita et al., eds., J. B. Lippincott Company,
Philadelphia, Pa., 1985). However, it is recognized that such
approaches continue to be limited by an inability to predict the
likelihood of metastasis and tumor recurrence or the most
efficacious treatment regime for minimizing the occurrence of these
negative outcomes.
Human cancer cells typically contain somatically altered nucleic
acids, characterized by mutation, amplification, or deletion of
critical genes. In addition, the nucleic acids from human cancer
cells often display somatic changes in DNA methylation (36, 37,
38). However, a precise role for, and the significance of, abnormal
DNA methylation in human tumorigenesis has not been well
established.
Loss of gene function is cancer can occur by both genetic and
epigenetic mechanisms. The best-defined epigenetic alteration of
cancer genes involves DNA methylation of clustered CpG
dinucleotides, or CpG islands, in promoter regions associated with
the transcriptional inactivation of the affected genes. CpG islands
are short sequences rich in the CpG dinucleotide, and can be found
in the 5' region of about half of all human genes. Methylation of
cytosine within 5' CGIs is associated with loss of gene expression
and has been seen in a number of physiological conditions,
including X chromosome inactivation and genomic imprinting.
Aberrant methylation of CpG islands has been detected in genetic
diseases such as the fragile-X syndrome, in aging cells and in
neoplasia. About half of the tumor suppressor genes which have been
shown to be mutated in the germline of patients with familial
cancer syndromes have also been shown to be aberrantly methylated
in some proportion of sporadic cancers, including Rb, VHL, p16,
hMLH1, and BRCA1 (reviewed in Baylin, et al, Adv. Cancer Res.
72:141-196 1998). Methylation of tumor suppressor genes in cancer
is usually associated with (1) lack of gene transcription and (2)
absence of coding region mutation. Thus CpG island methylation can
serve as an alternative mechanism of gene inactivation in
cancer.
Cancer treatments, in general, have a higher rate of success if the
cancer is diagnosed early, and treatment is started earlier in the
disease process. A relationship between improved prognosis and
stage of disease at diagnosis can be seen across a majority of
cancers. Identification of the earliest changes in cells associated
with cancer is thus a major focus in molecular cancer research.
Diagnostic approaches based on identification of these changes in
specific genes may allow implementation of early detection
strategies and novel therapeutic approaches. Targeting these early
changes will lead to more effective cancer treatment.
Despite advances in targeted therapy, surgery with curative intent
remains the best therapeutic option for lung cancer patients with
the earliest stages of disease. Ensuring in these patients that no
occult metastatic cells have disseminated outside the area of
curative resection is critical, because early spread of tumor cells
is a leading cause of relapse (1-3). Despite the curative aim of
early surgery, approximately 30%-40% of lung cancer patients with
discrete lesions and histologically proven cancer negative lymph
nodes (stage 1:T1-2N0) still die of recurrent disease (4-6).
Further, many of these recurrences are systemic, underscoring the
probability that these patients had metastatic disease that was
undetectable, and beyond the margins of surgical resection.
Accordingly, there is a need in the art for improved methods of
detection of proliferative disease, and in particular, for improved
methods of detection of metastatic cancer that is undetectable by
current methodologies.
SUMMARY
The invention features methods for identifying metastases by
detecting nucleic acid hypermethylation of one or more genes in one
or more samples, and in particular in tumor tissue and lymph
nodes.
In one aspect, the invention features methods for identifying
metastases in a subject comprising detecting nucleic acid
hypermethylation of one or more genes in one or more samples,
wherein detecting nucleic acid hypermethylation identifies
metastases.
In one embodiment, the sample comprises cells or tissues selected
from the group consisting of tumor, lymph nodes, bone marrow and
blood. In a particular embodiment, the sample is from a tumor. In
another particular embodiment, the sample is from a lymph node. In
a more particular embodiment, the lymph node is a N1 lymph node or
a mediastinal lymph node.
In another aspect the invention features methods for identifying
metastases in a subject comprising detecting nucleic acid
hypermethylation of one or more genes in tumor tissue or lymph
node, wherein the genes are selected from the group consisting of
genes involved in tumor suppression, DNA repair, apoptosis,
anti-proliferation, ras signaling, adhesion, differentiation,
development, and cell cycle regulation, wherein detecting nucleic
acid hypermethylation identifies metastases.
In certain preferred embodiments of the above aspects, the
metastases are micrometastases. In other preferred embodiments of
the above aspects, the one or more genes comprise one or more CpG
islands. In a further embodiment, the one or more genes is selected
from the group consisting of H-cadherin, p16, APC, RASSF1A, MGMT,
DAPK, and ASC.
H-cadherin, in certain exemplary embodiments is encoded by NCBI
accession No. AAB18912 and is shown in (SEQ ID NO:1) below:
TABLE-US-00001 1 mqprtplvlc vllsqvlllt saedldctpg fqqkvfhinq
paefiedqsi lnltfsdckg 61 ndklryevss pyfkvnsdgg lvalrnitav
gktlfvhart phaedmaelv ivggkdiqgs 121 lqdifkfart spvprqkrsi
vvspilipen qrqpfprdvg kvvdsdrper skfrltgkgv 181 dqepkgifri
nentgsvsvt rtldreviav yqlfvettdv ngktlegpvp levividqnd 241
nrpifregpy ighvmegspt gttvmrmtaf daddpatdna llrynirqqt pdkpspnmfy
301 idpekgdivt vvspalldre tlenpkyeli ieaqdmagld vgltgtatat
imiddkndhs 361 pkftkkefqa tveegavgvi vnltvedkdd pttgawraay
tiingnpgqs feihtnpqtn 421 egmlsvvkpl dyeisafhtl likvenedpl
vpdvsygpss tatvhitvld vnegpvfypd 481 pmmvtrqedl svgsvlltvn
atdpdslqhq tirysvykdp agwlninpin gtvdttavld 541 respfvdnsv
ytalflaids gnppatgtgt llitledvnd napfiyptva evcddaknls 601
vvilgasdkd lhpntdpfkf eihkqavpdk vwkiskinnt halvsllqnl nkanynlpim
661 vtdsgkppmt nitdlrvqvc scrnskvdcn aagalrfslp svlllslfsl acl
p-16, in certain exemplary embodiments is encoded by NCBI accession
No. CAB58124 and is shown in (SEQ ID NO:2) below:
TABLE-US-00002 1 gshsmryfft svsrpgrgep rfiavgyvdd tqfvrfdsda
asqrmeprap wieqegpeyw 61 dgetrkvkah sqtdrvdlgt lrgyynqsea
gshtiqmmyg cdvgpdgrll rgyqqdaydg 121 kdyialnedl rswtaadmaa
qitqrkweaa rvaeqlrayl egtcvewlrr ylengketlq 181 rt
APC, in certain exemplary embodiments is encoded by NCBI accession
No. NP_000029 and is shown in (SEQ ID NO:3) below:
TABLE-US-00003 1 maaasydqll kqvealkmen snlrqeledn snhltklete
asnmkevlkq lqgsiedeam 61 assgqidlle rlkelnldss nfpgvklrsk
mslrsygsre gsvssrsgec spvpmgsfpr 121 rgfvngsres tgyleeleke
rsllladldk eekekdwyya qlqnltkrid slpltenfsl 181 qtdmtrrqle
yearqirvam eeqlgtcqdm ekraqrriar iqqiekdilr irqllqsqat 241
eaerssqnkh etgshdaerq negqgvgein matsgngqgs ttrmdhetas vlssssthsa
301 prrltshlgt kvemvyslls mlgthdkddm srtllamsss qdscismrqs
gclplliqll 361 hgndkdsvll gnsrgskear arasaalhni ihsqpddkrg
rreirvlhll eqiraycetc 421 wewqeahepg mdqdknpmpa pvehqicpav
cvlmklsfde ehrhamnelg glqaiaellq 481 vdcemygltn dhysitlrry
agmaltnltf gdvankatlc smkgcmralv aqlksesedl 541 qqviasvlrn
lswradvnsk ktlrevgsvk almecalevk kestlksvls alwnlsahct 601
enkadicavd galaflvgtl tyrsqtntla iiesgggilr nvssliatne dhrqilrenn
661 clqtllqhlk shsltivsna cgtlwnlsar npkdqealwd mgavsmlknl
ihskhkmiam 721 gsaaalrnlm anrpakykda nimspgsslp slhvrkqkal
eaeldaqhls etfdnidnls 781 pkashrskqr hkqslygdyv fdtnrhddnr
sdnfntgnmt vlspylnttv lpsssssrgs 841 ldssrsekdr slerergigl
gnyhpatenp gtsskrglqi sttaaqiakv meevsaihts 901 qedrssgstt
elhcvtdern alrrssaaht hsntynftks ensnrtcsmp yakleykrss 961
ndslnsvsss dgygkrgqmk psiesysedd eskfcsygqy padlahkihs anhmddndge
1021 ldtpinyslk ysdeqlnsgr qspsqnerwa rpkhiiedei kqseqrqsrn
qsttypvyte 1081 stddkhlkfq phfgqqecvs pyrsrgangs etnrvgsnhg
inqnvsqslc qeddyeddkp 1141 tnyserysee eqheeeerpt nysikyneek
rhvdqpidys lkyatdipss qkqsfsfsks 1201 ssgqsskteh mssssentst
pssnakrqnq lhpssaqsrs gqpqkaatck vssinqetiq 1261 tycvedtpic
fsrcsslssl ssaedeigcn qttqeadsan tlqiaeikek igtrsaedpv 1321
sevpavsqhp rtkssrlqgs slssesarhk avefssgaks psksgaqtpk sppehyvqet
1381 plmfsrctsv ssldsfesrs iassvqsepc sgmvsgiisp sdlpdspgqt
mppsrsktpp 1441 pppqtaqtkr evpknkapta ekresgpkqa avnaavqrvq
vlpdadtllh fatestpdgf 1501 scssslsals ldepfiqkdv elrimppvqe
ndngnetese qpkesnenqe keaektidse 1561 kdllddsddd dieileecii
samptkssrk akkpaqtask lpppvarkps qlpvykllps 1621 qnrlqpqkhv
sftpgddmpr vycvegtpin fstatslsdl tiesppnela agegvrggaq 1681
sgefekrdti ptegrstdea qggktssvti pelddnkaee gdilaecins ampkgkshkp
1741 frvkkimdqv qqasasssap nknqldgkkk kptspvkpip qnteyrtrvr
knadsknnln 1801 aervfsdnkd skkqnlknns kvfndklpnn edrvrgsfaf
dsphhytpie gtpycfsrnd 1861 slssldfddd dvdlsrekae lrkakenkes
eakvtshtel tsnqqsankt qaiakqpinr 1921 gqpkpilqkq stfpqsskdi
pdrgaatdek lqnfaientp vcfshnssls slsdidqenn 1981 nkenepiket
eppdsqgeps kpqasgyapk sfhvedtpvc fsrnsslssl sidseddllq 2041
ecissampkk kkpsrlkgdn ekhsprnmgg ilgedltldl kdiqrpdseh glspdsenfd
2101 wkaiqegans ivsslhqaaa aaclsrqass dsdsilslks gislgspfhl
tpdqeekpft 2161 snkgprilkp gekstletkk ieseskgikg gkkvykslit
gkvrsnseis gqmkqplqan 2221 mpsisrgrtm ihipgvrnss sstspvskkg
pplktpasks psegqtatts prgakpsvks 2281 elspvarqts qiggsskaps
rsgsrdstps rpaqqplsrp iqspgrnsis pgrngisppn 2341 klsqlprtss
pstastkssg sgkmsytspg rqmsqqnltk qtglsknass iprsesaskg 2401
lnqmnngnga nkkvelsrms stkssgsesd rserpvlvrq stfikeapsp tlrrkleesa
2461 sfeslspssr pasptrsqaq tpvlspslpd mslsthssvq aggwrklppn
lsptieyndg 2521 rpakrhdiar shsespsrlp inrsgtwkre hskhssslpr
vstwrrtgss ssilsasses 2581 sekaksedek hvnsisgtkq skenqvsakg
twrkikenef sptnstsqtv ssgatngaes 2641 ktliyqmapa vsktedvwvr
iedcpinnpr sgrsptgntp pvidsvseka npnikdskdn 2701 qakqnvgngs
vpmrtvglen rlnsfiqvda pdqkgteikp gqnnpvpvse tnessivert 2761
pfsssssskh sspsgtvaar vtpfnynpsp rkssadstsa rpsqiptpvn nntkkrdskt
2821 dstessgtqs pkrhsgsylv tsv
RASSF1A, in certain exemplary embodiments is encoded by NCBI
accession No. NP_009113 and is shown in (SEQ ID NO:4) below:
TABLE-US-00004 1 msgepeliel relapagrag kgrtrleran alriargtac
nptrqlvpgr ghrfqpagpa 61 thtwcdlcgd fiwgvvrkgl qcahckftch
yrcralvcld ccgprdlgwe paverdtnvd 121 epvewetpdl sqaeieqkik
eynaqinsnl fmslnkdgsy tgfikvqlkl vrpvsvpssk 181 kppslqdarr
gpgrgtsvrr rtsfylpkda vkhlhvlsrt rarevieall rkflvvddpr 241
kfalferaer hgqvylrkll ddeqplrlrl lagpsdkals fvlkendsge vnwdafsmpe
301 lhnflrilqr eeeehlrqil qkysycrqki qealhacplg
MGMT, in certain exemplary embodiments is encoded by NCBI accession
No. AAH00824 and is shown in (SEQ ID NO:5) below:
TABLE-US-00005 1 mdkdcemkrt tldsplgkle lsgceqglhe ikllgkgtsa
adavevpapa avlggpeplm 61 qctawlnayf hqpeaieefp vpalhhpvfq
qesftrqvlw kllkvvkfge visyqqlaal 121 agnpkaarav ggamrgnpvp
ilipchrvvc ssgavgnysg glavkewlla heghrlgkpg 181 lggssglaga
wlkgagatsg sppagrn
DAPK, in certain exemplary embodiments is encoded by NCBI accession
No. NP_004929 and is shown in (SEQ ID NO:6) below:
TABLE-US-00006 1 mtvfrqenvd dyydtgeelg sgqfavvkkc rekstglqya
akfikkrrtk ssrrgvsred 61 ierevsilke iqhpnvitlh evyenktdvi
lilelvagge lfdflaekes lteeeatefl 121 kqilngvyyl hslqiahfdl
kpenimlldr nvpkprikii dfglahkidf gnefknifgt 181 pefvapeivn
yeplgleadm wsigvityil lsgaspflgd tkqetlanvs avnyefedey 241
fsntsalakd firrllvkdp kkrmtiqdsl qhpwikpkdt qqalsrkasa vnmekfkkfa
301 arkkwkqsvr lislcqrlsr sflsrsnmsv arsddtldee dsfvmkaiih
ainddnvpgl 361 qhllgslsny dvnqpnkhgt pplliaagcg niqilqllik
rgsridvqdk ggsnavywaa 421 rhghvdtlkf lsenkcpldv kdksgemalh
vaaryghadv aqllcsfgsn pniqdkeeet 481 plhcaawhgy ysvakalcea
gcnvniknre getplltasa rgyhdivecl aehgadlnac 541 dkdghialhl
avrrcqmevi ktllsqgcfv dyqdrhgntp lhvackdgnm pivvalcean 601
cnldisnkyg rtplhlaann gildvvrylc lmgasvealt tdgktaedla rseqhehvag
661 llarlrkdth rglfiqqlrp tqnlqprikl klfghsgsgk ttlveslkcg
llrsffrrrr 721 prlsstnssr fppsplaskp tvsvsinnly pgcenvsvrs
rsmmfepglt kgmlevfvap 781 thhphcsadd qstkaidiqn aylngvgdfs
vwefsgnpvy fccydyfaan dptsihvvvf 841 sleepyeiql nqvifwlsfl
kslvpveepi afggklknpl qvvlvathad imnvprpagg 901 efgydkdtsl
lkeirnrfgn dlhisnklfv ldagasgskd mkvlrnhlqe irsqivsvcp 961
pmthlcekii stlpswrkln gpnqlmslqq fvydvqdqln plaseedlrr iaqqlhstge
1021 inimqsetvq dvllldprwl ctnvlgklls vetpralhhy rgrytvediq
rlvpdsdvee 1081 llqildamdi cardlssgtm vdvpaliktd nlhrswadee
devmvyggvr ivpvehltpf 1141 pcgifhkvqv nlcrwihqqs tegdadirlw
vngcklanrg aellvllvnh gqgievqvrg 1201 letekikccl lldsvcstie
nvmattlpgl ltvkhylspq qlrehhepvm iyqprdffra 1261 qtlketsltn
tmggykesfs simcfgchdv ysqaslgmdi hasdlnlltr rklsrlldpp 1321
dplgkdwcll amnlglpdlv akyntsngap kdflpsplha llrewttype stvgtlmskl
1381 relgrrdaad fllkassvfk inldgngqea yasscnsgts ynsissvvsr
ASC, in certain exemplary embodiments is encoded by NCBI accession
No. NP_037390 and is shown in (SEQ ID NO:7) below:
TABLE-US-00007 1 mgrardaild alenltaeel kkfklkllsv plregygrip
rgallsmdal dltdklvsfy 61 letygaelta nvlrdmglqe magqlqaath
qgsgaapagi qappqsaakp glhfidqhra 121 aliarvtnve wlldalygkv
ltdeqyqavr aeptnpskmr klfsftpawn wtckdlllqa 181 lresqsylve
dlers
In other embodiments of the above aspects, hypermethylation of at
least one of the genes is detected. In still other embodiments of
the above aspects, hypermethylation of at least two of the genes is
detected.
In other aspects, the invention features methods for identifying
micrometastases in a subject comprising detecting nucleic acid
hypermethylation of at least one or more genes in a sample
comprising tumor and lymph nodes, wherein the sample genes are
selected from the group consisting of H-cadherin, p16, APC,
RASSF1A, MGMT, DAPK, and ASC, and wherein detecting nucleic acid
methylation identifies micrometastases.
In a preferred embodiment, hypermethylation of at least two of the
genes is detected. In another embodiment, at least two of the genes
are selected from p-16 and H-cadherin, H-cadherin and APC, APC and
p16, or RASSf1A and p16.
In another further embodiment, the detection of metastases is used
to detect or diagnose a proliferative disease.
In certain embodiments, the detection or diagnosis is performed
after surgery or therapy to treat a proliferative disease. In other
certain embodiments, the detection is used to predict the
recurrence of a proliferative disease. In other certain
embodiments, the detection is used to stage a proliferative
disease. In still other certain embodiments, the detection is
further used to determine a course of treatment for a subject.
In other aspects, the invention features a method for detecting or
diagnosing a proliferative disease in a subject comprising
detecting nucleic acid hypermethylation of one or more genes in one
or more samples, wherein detecting nucleic acid hypermethylation is
used to detect or diagnose a proliferative disease.
In still other aspects, the invention features a method for
predicting the recurrence of a proliferative disease in a subject
comprising detecting nucleic acid hypermethylation of one or more
genes wherein detecting nucleic acid hypermethylation of one or
more genes is a predictor of the recurrence of a proliferative
disease.
In one embodiment, hypermethylation of one or more genes is
detected in tumor or lymph nodes.
In a related embodiment, detection of hypermethylation of one or
more genes in lymph nodes is predictive of aggressive disease
recurrence.
In another aspect, the invention features a method for staging or
re-staging a proliferative disease in a subject comprising
detecting nucleic acid hypermethylation of one or more genes
wherein detecting nucleic acid hypermethylation is used for staging
or re-staging a proliferative disease.
In a related embodiment, the stage of proliferative disease is
predictive of disease recurrence. In a further embodiment, the
stage of proliferative disease determines course of treatment.
In another aspect, the invention features a method for determining
the prognosis of a subject suffering from a proliferative disease
comprising detecting nucleic acid hypermethylation of one or more
genes wherein the detection of nucleic acid hypermethylation is
used for determining the prognosis of a subject suffering from a
proliferative disease.
In a related embodiment, the prognosis determines course of
treatment.
In an embodiment of any of the above-mentioned aspects, the subject
is a human.
In another embodiment of any of the above-mentioned aspects, the
method is performed prior to therapeutic intervention for the
disease.
In another embodiment of any of the above-mentioned aspects, the
method is performed after therapeutic intervention for the disease.
In a related embodiment, the therapeutic intervention is selected
from treatment with an agent or surgery. In another related
embodiment, hypermethylation is detected in CpG islands of the one
or more genes. In a further related embodiment, hypermethylation is
detected in CpG islands.
In another aspect, the invention features methods for detecting or
diagnosing a proliferative disease in a subject comprising
extracting nucleic acid from one or more cell or tissue samples,
detecting nucleic acid hypermethylation of one or more genes in the
sample; and identifying the nucleic acid hypermethylation state of
one or more genes, wherein nucleic acid hypermethylation of genes
indicates a proliferative disease.
In a further aspect, the invention features methods for predicting
the recurrence of a proliferative disease in a subject comprising
extracting nucleic acid from one or more cell or tissue samples,
detecting nucleic acid hypermethylation of one or more genes in the
sample; and identifying the nucleic acid hypermethylation state of
one or more genes, wherein nucleic acid hypermethylation of genes
is indicative of the recurrence of a proliferative disease.
In a further aspect, the invention features methods for staging or
re-staging a proliferative disease in a subject comprising
extracting nucleic acid from one or more cell or tissue samples,
detecting nucleic acid hypermethylation of one or more genes in the
sample; and identifying the nucleic acid hypermethylation state of
one or more genes, wherein nucleic acid hypermethylation of genes
is used for staging or re-staging of a proliferative disease.
In one embodiment of the above-mentioned aspects, the tissue
samples are selected from tumor, lymph node, bone marrow or blood
or a combination thereof.
In another embodiment of the above-mentioned aspects, the method
determines the course of disease treatment.
In still another embodiment of the above-mentioned aspects, the
method is performed prior to therapeutic intervention for the
disease.
In still another embodiment of the above-mentioned aspects, the
method is performed after therapeutic intervention for the
disease.
In a further embodiment, the therapeutic intervention is selected
from treatment with an agent or surgery.
In another aspect, the invention features methods of treating a
subject having or at risk for having a proliferative disease
comprising identifying nucleic acid hypermethylation of one or more
genes, where nucleic acid hypermethylation indicates having or a
risk for having a proliferative disease, and administering to the
subject a therapeutically effective amount of a demethylating
agent, thereby treating a subject having or at risk for having a
proliferative disease.
In one particular embodiment, the method is used in combination
with one or more chemotherapeutic agents.
In another particular embodiment of the above-mentioned aspects,
the method further comprises comparing the nucleic acid
hypermethylation of one or more genes in the sample with comparable
samples obtained from a normal subject.
In a further embodiment of the above-mentioned aspects, detecting
nucleic acid hypermethylation of one or more genes indicates the
presence of metastases.
In a particular embodiment, the metastases are micrometastases.
In another particular embodiment of any one of the above-mentioned
aspects, the proliferative disease is a neoplasia. In a preferred
embodiment, the neoplasia is cancer. In another preferred
embodiment, the cancer is a solid tumor. In a further embodiment,
the cancer is selected from the group consisting of lung cancer,
pancreatic cancer, esophageal cancer, head and neck cancer, stomach
cancer, liver cancer, prostate cancer, gastrointestinal cancer,
ovarian cancer, and uterine cancer.
In another particular embodiment of the above-mentioned aspects,
the cells or tissues are selected from the group consisting of
tumor, lymph nodes, bone marrow or blood. In a related embodiment,
the cells or tissues are from a tumor or the lymph nodes. In a
further embodiment, the lymph node is a N1 lymph node or a
mediastinal lymph node.
In another aspect, the invention features a method of identifying
an agent that de-methylates hypermethylated nucleic acid comprising
identifying one or more cell or tissue samples with hypermethylated
nucleic acid, extracting the hypermethylated nucleic acid,
contacting the nucleic acid with one or more nucleic acid
de-methylating candidate agents and a control agent, identifying
the nucleic acid hypermethylation state, wherein nucleic acid
de-methylation of genes in the sample by the candidate agent
compared to the control indicates a demethylating agent, and
thereby identifying an agent that de-methylates hypermethylated
nucleic acid.
In one embodiment of any of the above-mentioned aspects, the one or
more genes are selected from the group consisting of genes involved
in tumor suppression, DNA repair, anti-proliferation, apoptosis,
ras signaling, adhesion, differentiation, development, and cell
cycle regulation.
In another embodiment of any of the above-mentioned aspects, the
one or more genes are selected from a panel consisting of (1) genes
involved in tumor suppression and cell adhesion, (2) genes involved
in cell cycle regulation and adhesion, (3) genes involved in tumor
suppression and cell cycle regulation, and (4) genes involved in
ras signaling and cell cycle control.
In still another embodiment of any of the above-mentioned aspects,
the one or more genes comprise one or more CpG islands.
In a related embodiment, the genes are selected from the group
consisting of p-16, H-cadherin, APC, RASSF1A, MGMT, DAPK, and
ASC.
In another related embodiment, the hypermethylation of at least one
of the genes is detected. In a further related embodiment, the
hypermethylation of at least two of the genes is detected. In still
another related embodiment, the two genes are selected from p-16
and H-cadherin, H-cadherin and APC, APC and p16, or RASSf1A and
p16.
In another embodiment of any of the above-mentioned aspects, the
detection of nucleic acid methylation is by a quantitative
method.
In another embodiment of any of the above-mentioned aspects, the
detection of nucleic acid methylation is carried out by polymerase
chain reaction (PCR) analysis. In a related embodiment, the PCR is
methylation specific PCR (MSP).
In a particular embodiment, the method of detecting nucleic acid
methylation is performed as a high-throughput method.
In another particular embodiment, the method is used in combination
with the detection of other epigenetic markers. In a particular
related embodiment, the other epigenetic markers are plasma or
tumor epigenetic markers.
In an embodiment of the above-described aspects, hypermethylation
is detected in CpG islands of the one or more genes. In a further
embodiment of the above-described aspects, hypermethylation is
detected in CpG islands of the promoter region.
In other aspects, the invention features kits for identifying the
nucleic acid hypermethylation state of one or more genes comprising
gene specific primers for use in polymerase chain reaction (PCR),
and instructions for use.
In still other aspects, the invention features kits for detecting
metastases by detecting nucleic acid hypermethylation of one or
more genes, the kit comprising gene specific primers for use in
polymerase chain reaction (PCR), and instructions for use.
In one embodiment, the metastases are micrometastases.
In another embodiment, the PCR is methylation specific PCR
(MSP).
In still another embodiment, the one or more genes are selected
from the group consisting of genes involved in tumor suppression,
DNA repair, anti-proliferation, apotosis, ras signaling, adhesion,
differentiation, development, and cell cycle regulation.
In another embodiment, the one or more genes are selected from a
panel consisting of (1) genes involved in tumor suppression and
cell adhesion, (2) genes involved in cell cycle regulation and
adhesion, (3) genes involved in tumor suppression and cell cycle
regulation, and (4) genes involved in ras signaling and cell cycle
control.
In a related embodiment, the one or more genes comprise one or more
CpG islands. In a further related embodiment, the CpG islands are
in the promoter region. In another related embodiment, the genes
are selected from the group consisting of p-16, H-cadherin, APC,
RASSF1A, MGMT, DAPK, and ASC
In another embodiment, the hypermethylation of at least one of the
genes is detected. In still another embodiment, the
hypermethylation of at least two of the genes is detected. In still
another further embodiment, the two genes are selected from p-16
and H-cadherin, H-cadherin and APC, APC and p16, or RASSf1A and
p16.
Other aspects of the invention are described infra.
BRIEF DESCRIPTION OF THE FIGURES
FIG. 1 shows the results of multivariate logistic regression
analysis performed using the four genes that exhibited the largest
univariate distribution differences in methylation: p16,
H-cadherin, APC, and RASSF1A.
FIG. 2 (A-L) are graphs showing Kaplan-Meier estimates of
recurrence-free survival of pathologic Stage 1 lung cancer patients
at the Johns Hopkins Hospital, according to number of methylated
genes in a 4-gene panel at time of surgical resection.
FIG. 3 shows Methylation Specific PCR for the H-cadherin gene. For
each sample, the presence of a visible PCR product in Lanes marked
U indicates the presence of an unmethylated promoter region
amplified and serves as a control for sample preparation; the
presence of product in Lanes M indicates a methylated gene promoter
and was scored as positive for methylation. * represents the
molecular weight marker.
DEFINITIONS
Unless defined otherwise, all technical and scientific terms used
herein have the meaning commonly understood by a person skilled in
the art to which this invention belongs. The following references
provide one of skill with a general definition of many of the terms
used in this invention: Singleton et al., Dictionary of
Microbiology and Molecular Biology (2nd ed. 1994); The Cambridge
Dictionary of Science and Technology (Walker ed., 1988); The
Glossary of Genetics, 5th Ed., R. Rieger et al. (eds.), Springer
Verlag (1991); and Hale & Marham, The Harper Collins Dictionary
of Biology (1991). As used herein, the following terms have the
meanings ascribed to them unless specified otherwise.
In this disclosure, "comprises," "comprising," "containing" and
"having" and the like can have the meaning ascribed to them in U.S.
Patent law and can mean "includes," "including," and the like;
"consisting essentially of" or "consists essentially" likewise has
the meaning ascribed in U.S. Patent law and the term is open-ended,
allowing for the presence of more than that which is recited so
long as basic or novel characteristics of that which is recited is
not changed by the presence of more than that which is recited, but
excludes prior art embodiments.
By "control" is meant a standard or reference condition.
The phrase "in combination with" is intended to refer to all forms
of administration that provide a de-methylating agent, or the
methods of the instant invention (e.g. methods of detection of
hypermethylation) together with a second agent, such as a
chemotherapeutic agent, or a de-methylating agent, where the two
are administered concurrently or sequentially in any order.
The term "agent" as used herein is meant to refer to a polypeptide,
polynucleotide, or fragment, or analog thereof, small molecule, or
other biologically active molecule.
The term "CpG island" refers to a sequence of nucleic acid with an
increased density relative to other nucleic acid regions of the
dinucleotide CpG.
The term "epigenetic marker" or "epigenetic change" as used herein
is meant to refer to a change in the DNA sequences or gene
expression by a process or processes that do not change the DNA
coding sequence itself. In an exemplary embodiment, methylation is
an epigenetic marker.
The term "hypermethylation" as used herein refers to the presence
of methylated alleles in one or more nucleic acids. In preferred
embodiments, hypermethylation is detected using methylation
specific polymerase chain reaction (MSP).
The term "metastases" is meant to refer to the spread of a
malignant tumor from its sight of origin. Cancer cells may
metastasize through the bloodstream, through the lymphatic system,
across body cavities, or any combination thereof. A metastatic
tumor can arise from a multitude of primary tumor types, including
but not limited to lung, breast, thyroid, head and neck, brain,
lymphoid, gastrointestinal (mouth, esophagus, stomach, small
intestine, colon, rectum), genito-urinary tract (uterus, ovary,
cervix, bladder, testicle, penis, prostate), kidney, pancreas,
liver, bone, muscle or skin.
The term "micrometastases" is meant to refer to a metastasis that
cannot be detected by routine histological evaluation, for example
by Hematoxylin and Eosin (H & E) staining and microscopic
assessment.
The term "neoplasm" or "neoplasia" as used herein refers to
inappropriately high levels of cell division, inappropriately low
levels of apoptosis, or both. A neoplasm creates an unstructured
mass (a tumor), which can be either benign or malignant. For
example, cancer is a neoplasia. Examples of cancers include,
without limitation, leukemias (e.g., acute leukemia, acute
lymphocytic leukemia, acute myelocytic leukemia, acute myeloblastic
leukemia, acute promyelocytic leukemia, acute myelomonocytic
leukemia, acute monocytic leukemia, acute erythroleukemia, chronic
leukemia, chronic myelocytic leukemia, chronic lymphocytic
leukemia), polycythemia vera, lymphoma (Hodgkin's disease,
non-Hodgkin's disease), Waldenstrom's macroglobulinemia, heavy
chain disease, and solid tumors such as sarcomas and carcinomas
(e.g., fibrosarcoma, myxosarcoma, liposarcoma, chondrosarcoma,
osteogenic sarcoma, chordoma, angiosarcoma, endotheliosarcoma,
lymphangiosarcoma, lymphangioendotheliosarcoma, synovioma,
mesothelioma, Ewing's tumor, leiomyosarcoma, rhabdomyosarcoma,
colon carcinoma, pancreatic cancer, breast cancer, ovarian cancer,
prostate cancer, squamous cell carcinoma, basal cell carcinoma,
adenocarcinoma, sweat gland carcinoma, sebaceous gland carcinoma,
papillary carcinoma, papillary adenocarcinomas, cystadenocarcinoma,
medullary carcinoma, bronchogenic carcinoma, renal cell carcinoma,
hepatoma, nile duct carcinoma, choriocarcinoma, seminoma, embryonal
carcinoma, Wilm's tumor, cervical cancer, uterine cancer,
testicular cancer, lung carcinoma, small cell lung carcinoma,
bladder carcinoma, epithelial carcinoma, glioma, astrocytoma,
medulloblastoma, craniopharyngioma, ependymoma, pinealoma,
hemangioblastoma, acoustic neuroma, oligodenroglioma, schwannoma,
meningioma, melanoma, neuroblastoma, and retinoblastoma).
Lymphoproliferative disorders are also considered to be
proliferative diseases.
The phrase "nucleic acid" as used herein refers to an
oligonucleotide, nucleotide, polynucleotide, or to a fragment of
any of these, to DNA or RNA of genomic or synthetic origin which
may be single-stranded or double-stranded and may represent a sense
or antisense strand, peptide nucleic acid (PNA), or to any DNA-like
or RNA-like material, natural or synthetic in origin. As will be
understood by those of skill in the art, when the nucleic acid is
RNA, the deoxynucleotides A, G, C, and T are replaced by
ribonucleotides A, G, C, and U, respectively.
The term "proliferative disorder" as used herein refers to an
abnormal growth of cells. A cell proliferative disorder as
described herein may be a neoplasm.
The term "promoter" or "promoter region" refers to a minimal
sequence sufficient to direct transcription or to render
promoter-dependent gene expression that is controllable for
cell-type specific, tissue-specific, or is inducible by external
signals or agents. Promoters may be located in the 5' or 3' regions
of the gene. Promoter regions, in whole or in part, of a number of
nucleic acids can be examined for sites of CpG-island
methylation.
The term "sample" as used herein refers to any biological or
chemical mixture for use in the method of the invention. The sample
can be a biological sample. The biological samples are generally
derived from a patient, preferably as a bodily fluid (such as tumor
tissue, lymph node, sputum, blood, bone marrow, cerebrospinal
fluid, phlegm, saliva, or urine) or cell lysate. The cell lysate
can be prepared from a tissue sample (e.g. a tissue sample obtained
by biopsy), for example, a tissue sample (e.g. a tissue sample
obtained by biopsy), blood, cerebrospinal fluid, phlegm, saliva,
urine, or the sample can be cell lysate.
The term "stage" or "staging" as used herein is meant to refer to
the extent or progression of proliferative disease, e.g. cancer, in
a subject. Staging can be "clinical" and is according to the "stage
classification" corresponding to the TNM classification ("Rinsho,
Byori, Genpatsusei Kangan Toriatsukaikiyaku (Clinical and
Pathological Codes for Handling Primary Liver Cancer)": 22p. Nihon
Kangangaku Kenkyukai (Liver Cancer Study Group of Japan) edition
(3rd revised edition), Kanehara Shuppan, 1992). Staging in certain
embodiments can refer to "molecular staging" as defined by nucleic
acid hypermethylation of one or more genes in one or more samples.
In preferred embodiments of the invention, the "molecular stage"
stage of a cancer is determined by detection of nucleic acid
hypermethylation of one or more genes in a sample from the lymph
nodes.
The term "subject" as used herein is meant to include vertebrates,
preferably a mammal. Mammals include, but are not limited to,
humans.
The term "tumor" as used herein is intended to include an abnormal
mass or growth of cells or tissue. A tumor can be benign or
malignant.
DETAILED DESCRIPTION OF THE INVENTION
The invention is based upon the discovery that the hypermethylation
of certain genes can serve as prognostic and diagnostic markers for
cellular proliferative disorders. This is the first time that
promoter hypermethylation of certain genes, such as p16,
H-cadherin, RASSf1A and APC, in the lymph nodes has been associated
with the ability to predict recurrence and aggressiveness of
certain cancers, such as lung cancer.
I. Detection of Methylation
DNA methylases transfer methyl groups from the universal methyl
donor S-adenosyl methionine to specific sites on the DNA. Several
biological functions have been attributed to the methylated bases
in DNA. The most established biological function for methylated DNA
is the protection of DNA from digestion by cognate restriction
enzymes. The restriction modification phenomenon has, so far, been
observed only in bacteria. Mammalian cells, however, possess a
different methylase that exclusively methylates cytosine residues
that are 5' neighbors of guanine (CpG). This modification of
cytosine residues has important regulatory effects on gene
expression, especially when involving CpG rich areas, known as CpG
islands, located in the promoter regions of many genes.
Methylation has been shown by several lines of evidence to play a
role in gene activity, cell differentiation, tumorigenesis,
X-chromosome inactivation, genomic imprinting and other major
biological processes (Razin, A., H., and Riggs, R. D. eds. in DNA
Methylation Biochemistry and Biological Significance,
Springer-Verlag, New York, 1984). In eukaryotic cells, methylation
of cytosine residues that are immediately 5' to a guanosine, occurs
predominantly in CG poor regions (Bird, A., Nature, 321:209, 1986).
In contrast, CpG islands remain unmethylated in normal cells,
except during X-chromosome inactivation and parental specific
imprinting (Li, et al., Nature, 366:362, 1993) where methylation of
5' regulatory regions can lead to transcriptional repression. De
novo methylation of the Rb gene has been demonstrated in a small
fraction of retinoblastomas (Sakai, et al., Am. J. Hum. Genet.,
48:880, 1991), and recently, a more detailed analysis of the VHL
gene showed aberrant methylation in a subset of sporadic renal cell
carcinomas (Herman, et al., Proc. Natl. Acad. Sci., U.S.A.,
91:9700, 1994). Expression of a tumor suppressor gene can also be
abolished by de novo DNA methylation of a normally unmethylated CpG
island (Issa, et al., Nature Genet., 7:536, 1994; Herman, et al.,
supra; Merlo, et al., Nature Med., 1:686, 1995; Herman, et al.,
Cancer Res., 56:722, 1996; Graff, et al., Cancer Res., 55:5195,
1995; Herman, et al., Cancer Res., 55:4525, 1995).
In higher order eukaryotes DNA is methylated only at cytosines
located 5' to guanosine in the CpG dinucleotide. This modification
has important regulatory effects on gene expression, especially
when involving CpG rich areas, known as CpG islands, located in the
promoter regions of many genes. While almost all gene-associated
islands are protected from methylation on autosomal chromosomes,
extensive methylation of CpG islands has been associated with
transcriptional inactivation of selected imprinted genes and genes
on the inactive X-chromosome of females. Aberrant methylation of
normally unmethylated CpG islands has been described as a frequent
event in immortalized and transformed cells, and has been
associated with transcriptional inactivation of defined tumor
suppressor genes in human cancers.
Any method that is sufficient to detect hypermethylation, e.g. a
method that can detect methylation of nucleotides at levels as low
as 0.1%, is a suitable for use in the methods of the invention. A
number of different methods can be used to detect
hypermethylation.
The ability to monitor the real-time progress of the PCR changes
the way one approaches PCR-based quantification of DNA and RNA.
Reactions are characterized by the point in time during cycling
when amplification of a PCR product is first detected rather than
the amount of PCR product accumulated after a fixed number of
cycles. The higher the starting copy number of the nucleic acid
target, the sooner a significant increase in fluorescence is
observed. An amplification plot is the plot of fluorescence signal
versus cycle number. In the initial cycles of PCR, there is little
change in fluorescence signal. This defines the baseline for the
amplification plot. An increase in fluorescence above the baseline
indicates the detection of accumulated PCR product. A fixed
fluorescence threshold can be set above the baseline. The parameter
C.sub.T (threshold cycle) is defined as the fractional cycle number
at which the fluorescence passes the fixed threshold. For example,
the PCR cycle number at which fluorescence reaches a threshold
value of 10 times the standard deviation of baseline emission may
be used as C.sub.T and it is inversely proportional to the starting
amount of target cDNA. A plot of the log of initial target copy
number for a set of standards versus C.sub.T is a straight line.
Quantification of the amount of target in unknown samples is
accomplished by measuring C.sub.T and using the standard curve to
determine starting copy number.
The entire process of calculating C.sub.TS, preparing a standard
curve, and determining starting copy number for unknowns can be
performed by software, for example that of the 7700 system or 7900
system of Applied Biosystems. Real-time PCR requires an
instrumentation platform that consists of a thermal cycler,
computer, optics for fluorescence excitation and emission
collection, and data acquisition and analysis software. These
machines, available from several manufacturers, differ in sample
capacity (some are 96-well standard format, others process fewer
samples or require specialized glass capillary tubes), method of
excitation (some use lasers, others broad spectrum light sources
with tunable filters), and overall sensitivity. There are also
platform-specific differences in how the software processes data.
Real-time PCR machines are available at core facilities or labs
that have the need for high throughput quantitative analysis.
Briefly, in the Q-PCR method the number of target gene copies can
be extrapolated from a standard curve equation using the absolute
quantitation method. For each gene, cDNA from a positive control is
first generated from RNA by the reverse transcription reaction.
Using about 1 .mu.l of this cDNA, the gene under investigation is
amplified using the primers by means of a standard PCR reaction.
The amount of amplicon obtained is then quantified by
spectrophotometry and the number of copies calculated on the basis
of the molecular weight of each individual gene amplicon. Serial
dilutions of this amplicon are tested with the Q-PCR assay to
generate the gene specific standard curve. Optimal standard curves
are based on PCR amplification efficiency from 90 to 100% (100%
meaning that the amount of template is doubled after each cycle),
as demonstrated by the slope of the standard curve equation. Linear
regression analysis of all standard curves should show a high
correlation (R.sup.2 coefficient .gtoreq.0.98). Genomic DNA can be
similarly quantified.
When measuring transcripts of a target gene, the starting material,
transcripts of a housekeeping gene are quantified as an endogenous
control. Beta-actin is one of the most used nonspecific
housekeeping genes. For each experimental sample, the value of both
the target and the housekeeping gene are extrapolated from the
respective standard curve. The target value is then divided by the
endogenous reference value to obtain a normalized target value
independent of the amount of starting material.
The above-described quantitative real-time PCR methodology has been
adapted to perform quantitative methylation-specific PCR (QM-MSP)
by utilizing the external primers pairs in round one (multiplex)
PCR and internal primer pairs in round two (real time MSP) PCR.
Thus each set of genes has one pair of external primers and two
sets of three internal primers/probe (internal sets are specific
for unmethylated or methylated DNA). The external primer pairs can
co-amplify a cocktail of genes, each pair selectively hybridizing
to a member of the panel of genes being investigated using the
invention method. The method of methylation-specific PCR (QM-MSP)
has been described in US Patent Application 20050239101,
incorporated by reference in its entirety herein.
Hypermethylation can be detected using two-stage, or "nested" PCR,
for example as described in U.S. Pat. No. 7,214,485, incorporated
by reference in its entirety herein. For example, two-stage, or
"nested" polymerase chain reaction method is disclosed for
detecting methylated DNA sequences at sufficiently high levels of
sensitivity to permit cancer screening in biological fluid samples,
such as sputum, obtained non-invasively.
A method for assessment of the methylation status of any group of
CpG sites within a CpG island, independent of the use of
methylation-sensitive restriction enzymes, is described in U.S.
Pat. No. 6,017,704 incorporated by reference in its entirety herein
and described briefly as follows. This method employs primers that
specific for the bisulfite reaction such that the PCR reaction
itself is used to distinguish between the chemically modified
methylated and unmethylated DNA, which adds an improved sensitivity
of methylation detection. Unlike previous genomic sequencing
methods for methylation identification which utilizes amplification
primers which are specifically designed to avoid the CpG sequences,
MSP primers themselves are specifically designed to recognize CpG
sites to take advantage of the differences in methylation to
amplify specific products to be identified by the invention assay.
The methods of MSP include modification of DNA by sodium bisulfite
or a comparable agent that converts all unmethylated but not
methylated cytosines to uracil, and subsequent amplification with
primers specific for methylated versus unmethylated DNA. This
method of "methylation specific PCR" or MSP, requires only small
amounts of DNA, is sensitive to 0.1% of methylated alleles of a
given CpG island locus, and can be performed on DNA extracted from
paraffin-embedded samples, for example. In addition, MSP eliminates
the false positive results inherent to previous PCR-based
approaches which relied on differential restriction enzyme cleavage
to distinguish methylated from unmethylated DNA.
MSP provides significant advantages over previous PCR and other
methods used for assaying methylation. MSP is markedly more
sensitive than Southern analyses, facilitating detection of low
numbers of methylated alleles and the study of DNA from small
samples. MSP allows the study of paraffin-embedded materials, which
could not previously be analyzed by Southern analysis. MSP also
allows examination of all CpG sites, not just those within
sequences recognized by methylation-sensitive restriction enzymes.
This markedly increases the number of such sites which can be
assessed and will allow rapid, fine mapping of methylation patterns
throughout CpG rich regions. MSP also eliminates the frequent false
positive results due to partial digestion of methylation-sensitive
enzymes inherent in previous PCR methods for detecting methylation.
Furthermore, with MSP, simultaneous detection of unmethylated and
methylated products in a single sample confirms the integrity of
DNA as a template for PCR and allows a semi-quantitative assessment
of allele types which correlates with results of Southern analysis.
Finally, the ability to validate the amplified product by
differential restriction patterns is an additional advantage.
MSP can provide similar information as genomic sequencing, but can
be performed with some advantages as follows. MSP is simpler and
requires less time than genomic sequencing, with a typical PCR and
gel analysis taking 4-6 hours. In contrast, genomic sequencing,
amplification, cloning, and subsequent sequencing may take days.
MSP also avoids the use of expensive sequencing reagents and the
use of radioactivity. Both of these factors make MSP better suited
for the analysis of large numbers of samples. The use of PCR as the
step to distinguish methylated from unmethylated DNA in MSP allows
for significant increase in the sensitivity of methylation
detection. For example, if cloning is not used prior to genomic
sequencing of the DNA, less than 10% methylated DNA in a background
of unmethylated DNA cannot be seen (Myohanen, et al., supra). The
use of PCR and cloning does allow sensitive detection of
methylation patterns in very small amounts of DNA by genomic
sequencing (Frommer, et al., Proc. Natl. Acad. Sci. USA, 89:1827,
1992; Clark, et al., Nucleic Acids Research, 22:2990, 1994).
However, this means in practice that it would require sequencing
analysis of 10 clones to detect 10% methylation, 100 clones to
detect 1% methylation, and to reach the level of sensitivity we
have demonstrated with MSP (1:1000), one would have to sequence
1000 individual clones.
"Multiplex methylation-specific PCR" is a unique version of
methylation-specific PCR. Methylation-specific PCR is described in
U.S. Pat. Nos. 5,786,146; 6,200,756; 6,017,704 and 6,265,171, each
of which is incorporated herein by reference in its entirety.
Multiplex methylation-specific PCR utilizes MSP primers for a
multiplicity of markers, for example three or more different
markers, in a two-stage nested PCR amplification reaction. The
primers used in the first PCR reaction are selected to amplify a
larger portion of the target sequence than the primers of the
second PCR reaction. The primers used in the first PCR reaction are
referred to herein as "external primers" or DNA primers" and the
primers used in the second PCR reaction are referred to herein as
"MSP primers." Two sets of primers (i.e., methylated and
unmethylated for each of the markers targeted in the reaction) are
used as the MSP primers. In addition in multiplex
methylation-specific PCR, as described herein, a small amount
(i.e., 1 .mu.l) of a 1:10 to about 10.sup.6 dilution of the
reaction product of the first "external" PCR reaction is used in
the second "internal" MSP PCR reaction.
The term "primer" as used herein refers to a sequence comprising
two or more deoxyribonucleotides or ribonucleotides, preferably
more than three, and most preferably more than 8, which sequence is
capable of initiating synthesis of a primer extension product,
which is substantially complementary to a polymorphic locus strand.
Environmental conditions conducive to synthesis include the
presence of nucleoside triphosphates and an agent for
polymerization, such as DNA polymerase, and a suitable temperature
and pH. The primer is preferably single stranded for maximum
efficiency in amplification, but may be double stranded. If double
stranded, the primer is first treated to separate its strands
before being used to prepare extension products. Preferably, the
primer is an oligodeoxy ribonucleotide. The primer must be
sufficiently long to prime the synthesis of extension products in
the presence of the inducing agent for polymerization. The exact
length of primer will depend on many factors, including
temperature, buffer, and nucleotide composition. The
oligonucleotide primer typically contains 12-20 or more
nucleotides, although it may contain fewer nucleotides.
Primers of the invention are designed to be "substantially"
complementary to each strand of the oligonucleotide to be amplified
and include the appropriate G or C nucleotides as discussed above.
This means that the primers must be sufficiently complementary to
hybridize with their respective strands under conditions that allow
the agent for polymerization to perform. In other words, the
primers should have sufficient complementarity with a 5' and 3'
oligonucleotide to hybridize therewith and permit amplification of
CpG containing nucleic acid sequence.
Primers of the invention are employed in the amplification process,
which is an enzymatic chain reaction that produces exponentially
increasing quantities of target locus relative to the number of
reaction steps involved (e.g., polymerase chain reaction or PCR).
Typically, one primer is complementary to the negative (-) strand
of the locus (antisense primer) and the other is complementary to
the positive (+) strand (sense primer). Annealing the primers to
denatured nucleic acid followed by extension with an enzyme, such
as the large fragment of DNA Polymerase I (Klenow) and nucleotides,
results in newly synthesized + and - strands containing the target
locus sequence. Because these newly synthesized sequences are also
templates, repeated cycles of denaturing, primer annealing, and
extension results in exponential production of the region (i.e.,
the target locus sequence) defined by the primer. The product of
the chain reaction is a discrete nucleic acid duplex with termini
corresponding to the ends of the specific primers employed.
The oligonucleotide primers used in invention methods may be
prepared using any suitable method, such as conventional
phosphotriester and phosphodiester methods or automated embodiments
thereof. In one such automated embodiment, diethylphos-phoramidites
are used as starting materials and may be synthesized as described
by Beaucage, et al. (Tetrahedron Letters, 22:1859-1862, 1981). One
method for synthesizing oligonucleotides on a modified solid
support is described in U.S. Pat. No. 4,458,066.
The primers used in the invention for amplification of the
CpG-containing nucleic acid in the specimen, after bisulfite
modification, specifically distinguish between untreated or
unmodified DNA, methylated, and non-methylated DNA. MSP primers for
the non-methylated DNA preferably have a T in the 3' CG pair to
distinguish it from the C retained in methylated DNA, and the
complement is designed for the antisense primer. MSP primers
usually contain relatively few Cs or Gs in the sequence since the
Cs will be absent in the sense primer and the Gs absent in the
antisense primer (C becomes modified to U (uracil) which is
amplified as T (thymidine) in the amplification product).
The primers of the invention embrace oligonucleotides of sufficient
length and appropriate sequence so as to provide specific
initiation of polymerization on a significant number of nucleic
acids in the polymorphic locus. Where the nucleic acid sequence of
interest contains two strands, it is necessary to separate the
strands of the nucleic acid before it can be used as a template for
the amplification process. Strand separation can be effected either
as a separate step or simultaneously with the synthesis of the
primer extension products. This strand separation can be
accomplished using various suitable denaturing conditions,
including physical, chemical, or enzymatic means, the word
"denaturing" includes all such means. One physical method of
separating nucleic acid strands involves heating the nucleic acid
until it is denatured. Typical heat denaturation may involve
temperatures ranging from about 80.degree. to 105.degree C. for
times ranging from about 1 to 10 minutes. Strand separation may
also be induced by an enzyme from the class of enzymes known as
helicases or by the enzyme RecA, which has helicase activity, and
in the presence of riboATP, is known to denature DNA. The reaction
conditions suitable for strand separation of nucleic acids with
helicases are described by Kuhn Hoffmann-Berling (CSH-Quantitative
Biology, 43:63, 1978) and techniques for using RecA are reviewed in
C. Radding (Ann. Rev. Genetics, 16:405-437, 1982).
As described herein, any nucleic acid specimen, in purified or
nonpurified form, can be utilized as the starting nucleic acid or
acids, provided it contains, or is suspected of containing, the
specific nucleic acid sequence containing the target locus (e.g.,
CpG).
When complementary strands of nucleic acid or acids are separated,
regardless of whether the nucleic acid was originally double or
single stranded, the separated strands are ready to be used as a
template for the synthesis of additional nucleic acid strands. This
synthesis is performed under conditions allowing hybridization of
primers to templates to occur. Generally synthesis occurs in a
buffered aqueous solution, preferably at a pH of 7-9, most
preferably about 8. Preferably, a molar excess (for genomic nucleic
acid, usually about 10.sup.8:1 primer:template) of the two
oligonucleotide primers is added to the buffer containing the
separated template strands. It is understood, however, that the
amount of complementary strand may not be known if the process of
the invention is used for diagnostic applications, so that the
amount of primer relative to the amount of complementary strand
cannot be determined with certainty. As a practical matter,
however, the amount of primer added will generally be in molar
excess over the amount of complementary strand (template) when the
sequence to be amplified is contained in a mixture of complicated
lona-chain nucleic acid strands. A large molar excess is preferred
to improve the efficiency of the process.
The deoxyribonucleoside triphosphates dATP, dCTP, dGTP, and dTTP
are added to the synthesis mixture, either separately or together
with the primers, in adequate amounts and the resulting solution is
heated to about 90 C-100 C. from about 1 to 10 minutes, preferably
from 1 to 4 minutes. After this heating period, the solution is
allowed to cool to room temperature, which is preferable for the
primer hybridization. To the cooled mixture is added an appropriate
agent for effecting the primer extension reaction (called herein
"agent for polymerization"), and the reaction is allowed to occur
under conditions known in the art. The agent for polymerization may
also be added together with the other reagents if it is heat
stable. This synthesis (or amplification) reaction may occur at
room temperature up to a temperature above which the agent for
polymerization no longer functions. Thus, for example, if DNA
polymerase is used as the agent, the temperature is generally no
greater than about 40 C. Most conveniently the reaction occurs at
room temperature.
In certain preferred embodiments, the agent for polymerization may
be any compound or system which will function to accomplish the
synthesis of primer extension products, including enzymes. Suitable
enzymes for this purpose include, for example, E. coli DNA
polymerase I, Klenow fragment of E. coli DNA polymerase I, T4 DNA
polymerase, other available DNA polymerases, polymerase muteins,
reverse transcriptase, and other enzymes, including heat-stable
enzymes (i.e., those enzymes which perform primer extension after
being subjected to temperatures sufficiently elevated to cause
denaturation). Suitable enzymes will facilitate combination of the
nucleotides in the proper manner to form the primer extension
products which are complementary to each locus nucleic acid strand.
Generally, the synthesis will be initiated at the 3' end of each
primer and proceed in the 5' direction along the template strand,
until synthesis terminates, producing molecules of different
lengths. There may be agents for polymerization, however, which
initiate synthesis at the 5' end and proceed in the other
direction, using the same process as described above.
In nucleic acid hybridization reactions, the conditions used to
achieve a particular level of stringency will vary, depending on
the nature of the nucleic acids being hybridized. For example, the
length, degree of complementarity, nucleotide sequence composition
(e.g., GC v. AT content), and nucleic acid type (e.g., RNA v. DNA)
of the hybridizing regions of the nucleic acids can be considered
in selecting hybridization conditions. An additional consideration
is whether one of the nucleic acids is immobilized, for example, on
a filter.
An example of progressively higher stringency conditions is as
follows: 2.times.SSC/0.1% SDS at about room temperature
(hybridization conditions); 0.2.times.SSC/0.1% SDS at about room
temperature (low stringency conditions); 0.2.times.SSC/0.1% SDS at
about 42.degree. C. (moderate stringency conditions); and
0.1.times.SSC at about 68.degree. C. (high stringency conditions).
Washing can be carried out using only one of these conditions,
e.g., high stringency conditions, or each of the conditions can be
used, e.g., for 10-15 minutes each, in the order listed above,
repeating any or all of the steps listed. However, as mentioned
above, optimal conditions will vary, depending on the particular
hybridization reaction involved, and can be determined
empirically.
Preferably, the method of amplifying is by PCR, as described herein
and as is commonly used by those of ordinary skill in the art.
Alternative methods of amplification have been described and can
also be employed as long as the methylated and non-methylated loci
amplified by PCR using the primers of the invention is similarly
amplified by the alternative means.
The amplified products are preferably identified as methylated or
non-methylated by sequencing. Sequences amplified by the methods of
the invention can be further evaluated, detected, cloned,
sequenced, and the like, either in solution or after binding to a
solid support, by any method usually applied to the detection of a
specific DNA sequence such as PCR, oligomer restriction (39),
allele-specific oligonucleotide (ASO) probe analysis (40),
oligonucleotide ligation assays (OLAs) (41), and the like.
Molecular techniques for DNA analysis have been reviewed (42).
Optionally, the methylation pattern of the nucleic acid can be
confirmed by restriction enzyme digestion and Southern blot
analysis. Examples of methylation sensitive restriction
endonucleases which can be used to detect 5'CpG methylation include
SmaI, SacII, EagI, MspI, HpaII, BstUI and BssHII, for example.
The invention provides a method for detecting a cell having a
hypermethylated CpG island or a cell proliferative disorder
associated with hypermethylated CpG in a tissue or biological fluid
of a subject, comprising contacting a target cellular component
suspected of expressing a gene having a methylated CpG or having a
CpG-associated disorder, with an agent which binds to the
component. The target cell component can be nucleic acid, such as
DNA or RNA, or protein. When the component is nucleic acid, the
reagent is a nucleic acid probe or PCR primer. When the cell
component is protein, the reagent is an antibody probe. The probes
can be detectably labeled, for example, with a radioisotope, a
fluorescent compound, a bioluminescent compound, a chemiluminescent
compound, a metal chelator, or an enzyme. Those of ordinary skill
in the art will know of other suitable labels for binding to the
antibody, or will be able to ascertain such, using routine
experimentation.
Actively transcribed genes generally contain fewer methylated CGs
than the average number in DNA. Hypermethylation can also be
detected by restriction endonuclease treatment and Southern blot
analysis. Therefore, in certain preferred embodiments, when the
cellular component detected is DNA, restriction endonuclease
analysis is preferable to detect hypermethylation of the promoter
for example. Any restriction endonuclease that includes CG as part
of its recognition site and that is inhibited when the C is
methylated can be utilized. In certain preferred examples, the
methylation sensitive restriction endonuclease is BssHII, MspI, or
HpaII, used alone or in combination. Other methylation sensitive
restriction endonucleases will be known to those of skill in the
art.
For purposes of the invention, an antibody or nucleic acid probe
specific for a gene or gene product may be used to detect the
presence of methylation either by detecting the level of
polypeptide (using antibody) or methylation of the polynucleotide
(using nucleic acid probe) in biological fluids or tissues. For
antibody-based detection, the level of the polypeptide is compared
with the level of polypeptide found in a corresponding "normal"
tissue. Oligonucleotide primers based on any coding sequence region
of the promoter in gene selected from genes involved in tumor
suppression, nucleic acid repair, apoptosis, anti-proliferation,
ras signaling, adhesion, differentiation, development, and cell
cycle regulation. In particular, oligonucleotide primers are based
on coding sequence region of the promoter in the gene selected from
the following are useful for amplifying DNA, for example by
PCR:
H-cadherin, in certain exemplary embodiments is encoded by NCBI
accession No. AAB18912, comprising (SEQ ID NO:1) below:
TABLE-US-00008 1 mqprtplvlc vllsqvlllt saedldctpg fqqkvfhinq
paefiedqsi lnltfsdckg 61 ndklryevss pyfkvnsdgg lvalrnitav
gktlfvhart phaedmaelv ivggkdiqgs 121 lqdifkfart spvprqkrsi
vvspilipen qrqpfprdvg kvvdsdrper skfrltgkgv 181 dqepkgifri
nentgsvsvt rtldreviav yqlfvettdv ngktlegpvp levividqnd 241
nrpifregpy ighvmegspt gttvmrmtaf daddpatdna llrynirqqt pdkpspnmfy
301 idpekgdivt vvspalldre tlenpkyeli ieaqdmagld vgltgtatat
imiddkndhs 361 pkftkkefqa tveegavgvi vnltvedkdd pttgawraay
tiingnpgqs feihtnpqtn 421 egmlsvvkpl dyeisafhtl likvenedpl
vpdvsygpss tatvhitvld vnegpvfypd 481 pmmvtrqedl svgsvlltvn
atdpdslqhq tirysvykdp agwlninpin gtvdttavld 541 respfvdnsv
ytalflaids gnppatgtgt llitledvnd napfiyptva evcddaknls 601
vvilgasdkd lhpntdpfkf eihkqavpdk vwkiskinnt halvsllqnl nkanynlpim
661 vtdsgkppmt nitdlrvqvc scrnskvdcn aagalrfslp svlllslfsl acl
p-16, in certain exemplary embodiments is encoded by NCBI accession
No. CAB58124 comprising (SEQ ID NO:2) below:
TABLE-US-00009 1 gshsmryfft svsrpgrgep rfiavgyvdd tqfvrfdsda
asqrmeprap wieqegpeyw 61 dgetrkvkah sqtdrvdlgt lrgyynqsea
gshtiqmmyg cdvgpdgrll rgyqqdaydg 121 kdyialnedl rswtaadmaa
qitqrkweaa rvaeqlrayl egtcvewlrr ylengketlq 181 rt
APC, in certain exemplary embodiments is encoded by NCBI accession
No. NP_000029 comprising (SEQ ID NO:3) below:
TABLE-US-00010 1 maaasydqll kqvealkmen snlrqeledn snhltklete
asnmkevlkq lqgsiedeam 61 assgqidlle rlkelnldss nfpgvklrsk
mslrsygsre gsvssrsgec spvpmgsfpr 121 rgfvngsres tgyleeleke
rsllladldk eekekdwyya qlqnltkrid slpltenfsl 181 qtdmtrrqle
yearqirvam eeqlgtcqdm ekraqrriar iqqiekdilr irqllqsqat 241
eaerssqnkh etgshdaerq negqgvgein matsgngqgs ttrmdhetas vlssssthsa
301 prrltshlgt kvemvyslls mlgthdkddm srtllamsss qdscismrqs
gclplliqll 361 hgndkdsvll gnsrgskear arasaalhni ihsqpddkrg
rreirvlhll eqiraycetc 421 wewqeahepg mdqdknpmpa pvehqicpav
cvlmklsfde ehrhamnelg glqaiaellq 481 vdcemygltn dhysitlrry
agmaltnltf gdvankatlc smkgcmralv aqlksesedl 541 qqviasvlrn
lswradvnsk ktlrevgsvk almecalevk kestlksvls alwnlsahct 601
enkadicavd galaflvgtl tyrsqtntla iiesgggilr nvssliatne dhrqilrenn
661 clqtllqhlk shsltivsna cgtlwnlsar npkdqealwd mgavsmlknl
ihskhkmiam 721 gsaaalrnlm anrpakykda nimspgsslp slhvrkqkal
eaeldaqhls etfdnidnls 781 pkashrskqr hkqslygdyv fdtnrhddnr
sdnfntgnmt vlspylnttv lpsssssrgs 841 ldssrsekdr slerergigl
gnyhpatenp gtsskrglqi sttaaqiakv meevsaihts 901 qedrssgstt
elhcvtdern alrrssaaht hsntynftks ensnrtcsmp yakleykrss 961
ndslnsvsss dgygkrgqmk psiesysedd eskfcsygqy padlahkihs anhmddndge
1021 ldtpinyslk ysdeqlnsgr qspsqnerwa rpkhiiedei kqseqrqsrn
qsttypvyte 1081 stddkhlkfq phfgqqecvs pyrsrgangs etnrvgsnhg
inqnvsqslc qeddyeddkp 1141 tnyserysee eqheeeerpt nysikyneek
rhvdqpidys lkyatdipss qkqsfsfsks 1201 ssgqsskteh mssssentst
pssnakrqnq lhpssaqsrs gqpqkaatck vssinqetiq 1261 tycvedtpic
fsrcsslssl ssaedeigcn qttqeadsan tlqiaeikek igtrsaedpv 1321
sevpavsqhp rtkssrlqgs slssesarhk avefssgaks psksgaqtpk sppehyvqet
1381 plmfsrctsv ssldsfesrs iassvqsepc sgmvsgiisp sdlpdspgqt
mppsrsktpp 1441 pppqtaqtkr evpknkapta ekresgpkqa avnaavqrvq
vlpdadtllh fatestpdgf 1501 scssslsals ldepfiqkdv elrimppvqe
ndngnetese qpkesnenqe keaektidse 1561 kdllddsddd dieileecii
samptkssrk akkpaqtask lpppvarkps qlpvykllps 1621 qnrlqpqkhv
sftpgddmpr vycvegtpin fstatslsdl tiesppnela agegvrggaq 1681
sgefekrdti ptegrstdea qggktssvti pelddnkaee gdilaecins ampkgkshkp
1741 frvkkimdqv qqasasssap nknqldgkkk kptspvkpip qnteyrtrvr
knadsknnln 1801 aervfsdnkd skkqnlknns kvfndklpnn edrvrgsfaf
dsphhytpie gtpycfsrnd 1861 slssldfddd dvdlsrekae lrkakenkes
eakvtshtel tsnqqsankt qaiakqpinr 1921 gqpkpilqkq stfpqsskdi
pdrgaatdek lqnfaientp vcfshnssls slsdidqenn 1981 nkenepiket
eppdsqgeps kpqasgyapk sfhvedtpvc fsrnsslssl sidseddllq 2041
ecissampkk kkpsrlkgdn ekhsprnmgg ilgedltldl kdiqrpdseh glspdsenfd
2101 wkaiqegans ivsslhqaaa aaclsrqass dsdsilslks gislgspfhl
tpdqeekpft 2161 snkgprilkp gekstletkk ieseskgikg gkkvykslit
gkvrsnseis gqmkqplqan 2221 mpsisrgrtm ihipgvrnss sstspvskkg
pplktpasks psegqtatts prgakpsvks 2281 elspvarqts qiggsskaps
rsgsrdstps rpaqqplsrp iqspgrnsis pgrngisppn 2341 klsqlprtss
pstastkssg sgkmsytspg rqmsqqnltk qtglsknass iprsesaskg 2401
lnqmnngnga nkkvelsrms stkssgsesd rserpvlvrq stfikeapsp tlrrkleesa
2461 sfeslspssr pasptrsqaq tpvlspslpd mslsthssvq aggwrklppn
lsptieyndg 2521 rpakrhdiar shsespsrlp inrsgtwkre hskhssslpr
vstwrrtgss ssilsasses 2581 sekaksedek hvnsisgtkq skenqvsakg
twrkikenef sptnstsqtv ssgatngaes 2641 ktliyqmapa vsktedvwvr
iedcpinnpr sgrsptgntp pvidsvseka npnikdskdn 2701 qakqnvgngs
vpmrtvglen rlnsfiqvda pdqkgteikp gqnnpvpvse tnessivert 2761
pfsssssskh sspsgtvaar vtpfnynpsp rkssadstsa rpsqiptpvn nntkkrdskt
2821 dstessgtqs pkrhsgsylv tsv
RASSF1A, in certain exemplary embodiments is encoded by NCBI
accession No. NP_009113 comprising (SEQ ID NO:4) below:
TABLE-US-00011 1 msgepeliel relapagrag kgrtrleran alriargtac
nptrqlvpgr ghrfqpagpa 61 thtwcdlcgd fiwgvvrkgl qcahckftch
yrcralvcld ccgprdlgwe paverdtnvd 121 epvewetpdl sqaeieqkik
eynaqinsnl fmslnkdgsy tgfikvqlkl vrpvsvpssk 181 kppslqdarr
gpgrgtsvrr rtsfylpkda vkhlhvlsrt rarevieall rkflvvddpr 241
kfalferaer hgqvylrkll ddeqplrlrl lagpsdkals fvlkendsge vnwdafsmpe
301 lhnflrilqr eeeehlrqil qkysycrqki qealhacplg
MGMT, in certain exemplary embodiments is encoded by NCBI accession
No. AAH00824 comprising (SEQ ID NO:5) below:
TABLE-US-00012 1 mdkdcemkrt tldsplgkle lsgceqglhe ikllgkgtsa
adavevpapa avlggpeplm 61 qctawlnayf hqpeaieefp vpalhhpvfq
qesftrqvlw kllkvvkfge visyqqlaal 121 agnpkaarav ggamrgnpvp
ilipchrvvc ssgavgnysg glavkewlla heghrlgkpg 181 lggssglaga
wlkgagatsg sppagrn
DAPK, in certain exemplary embodiments is encoded by NCBI accession
No. NP_004929 comprising (SEQ ID NO:6) below:
TABLE-US-00013 1 mtvfrqenvd dyydtgeelg sgqfavvkkc rekstglqya
akfikkrrtk ssrrgvsred 61 ierevsilke iqhpnvitlh evyenktdvi
lilelvagge lfdflaekes lteeeatefl 121 kqilngvyyl hslqiahfdl
kpenimlldr nvpkprikii dfglahkidf gnefknifgt 181 pefvapeivn
yeplgleadm wsigvityil lsgaspflgd tkqetlanvs avnyefedey 241
fsntsalakd firrllvkdp kkrmtiqdsl qhpwikpkdt qqalsrkasa vnmekfkkfa
301 arkkwkqsvr lislcqrlsr sflsrsnmsv arsddtldee dsfvmkaiih
ainddnvpgl 361 qhllgslsny dvnqpnkhgt pplliaagcg niqilqllik
rgsridvqdk ggsnavywaa 421 rhghvdtlkf lsenkcpldv kdksgemalh
vaaryghadv aqllcsfgsn pniqdkeeet 481 plhcaawhgy ysvakalcea
gcnvniknre getplltasa rgyhdivecl aehgadlnac 541 dkdghialhl
avrrcqmevi ktllsqgcfv dyqdrhgntp lhvackdgnm pivvalcean 601
cnldisnkyg rtplhlaann gildvvrylc lmgasvealt tdgktaedla rseqhehvag
661 llarlrkdth rglfiqqlrp tqnlqprikl klfghsgsgk ttlveslkcg
llrsffrrrr 721 prlsstnssr fppsplaskp tvsvsinnly pgcenvsvrs
rsmmfepglt kgmlevfvap 781 thhphcsadd qstkaidiqn aylngvgdfs
vwefsgnpvy fccydyfaan dptsihvvvf 841 sleepyeiql nqvifwlsfl
kslvpveepi afggklknpl qvvlvathad imnvprpagg 901 efgydkdtsl
lkeirnrfgn dlhisnklfv ldagasgskd mkvlrnhlqe irsqivsvcp 961
pmthlcekii stlpswrkln gpnqlmslqq fvydvqdqln plaseedlrr iaqqlhstge
1021 inimqsetvq dvllldprwl ctnvlgklls vetpralhhy rgrytvediq
rlvpdsdvee 1081 llqildamdi cardlssgtm vdvpaliktd nlhrswadee
devmvyggvr ivpvehltpf 1141 pcgifhkvqv nlcrwihqqs tegdadirlw
vngcklanrg aellvllvnh gqgievqvrg 1201 letekikccl lldsvcstie
nvmattlpgl ltvkhylspq qlrehhepvm iyqprdffra 1261 qtlketsltn
tmggykesfs simcfgchdv ysqaslgmdi hasdlnlltr rklsrlldpp 1321
dplgkdwcll amnlglpdlv akyntsngap kdflpsplha llrewttype stvgtlmskl
1381 relgrrdaad fllkassvfk inldgngqea yasscnsgts ynsissvvsr
ASC, in certain exemplary embodiments is encoded by NCBI accession
No. NP_037390 comprising (SEQ ID NO:7) below:
TABLE-US-00014 1 mgrardaild alenltaeel kkfklkllsv plregygrip
rgallsmdal dltdklvsfy 61 letygaelta nvlrdmglqe magqlqaath
qgsgaapagi qappqsaakp glhfidqhra 121 aliarvtnve wlldalygkv
ltdeqyqavr aeptnpskmr klfsftpawn wtckdlllqa 181 lresqsylve
dlers
These genes are merely listed as examples and are not meant to be
limiting.
In certain preferred embodiments of the invention the genes can be
detected in panels consisting of the following:
(1) genes involved in tumor suppression and cell adhesion
(2) genes involved in cell cycle regulation and adhesion
(3) genes involved in tumor suppression and cell cycle
regulation
(4) genes involved in ras signaling and cell cycle control.
Any specimen containing a detectable amount of polynucleotide or
antigen can be used. Preferably the subject is human.
The present invention provides the finding that gene
hypermethylation of not only the primary malignancy, but also lymph
nodes, may be used to restage and assess prognosis of patients with
stage I tumors, in particular examples patients with stage I non
small cell lung carcinoma (NSCLC). These markers are shown to also
be potential targets for reversal of gene silencing and may be
important in adjuvant approaches to reduce disease recurrence.
Using the methods of the invention, expression of any gene, such as
genes involved in tumor suppression, nucleic acid repair,
apoptosis, anti-proliferation, ras signaling, adhesion,
differentiation, development, and cell cycle regulation, can be
identified in a cell and the appropriate course of treatment can be
employed (e.g., sense gene therapy or drug therapy). The expression
pattern of the gene may vary with the stage of malignancy of a
cell, therefore, a sample such as NSCLC or breast tissue can be
screened with a panel of gene or gene product specific reagents
(i.e., nucleic acid probes or antibodies) to detect gene expression
and then diagnose the stage of malignancy of the cell.
Any of the methods as described herein can be used in high
throughput analysis of DNA methylation. For example, U.S. Pat. No.
7,144,701, incorporated by reference in its entirety herein,
describes differential methylation hybridization (DMH) for a
high-throughput analysis of DNA methylation.
II. Methods of Detection and Diagnosis
The methods of the invention as described herein are used in
certain exemplary embodiments to identify metastases by detecting
hypermethylation of one or more genes in one or more samples. In
this way, the detection of nucleic acid hypermethylation identifies
metastases.
In mammals, conditions associated with aberrant methylation of
genes that can be detected or monitored include, but are not
limited to, metastases associated with carcinomas and sarcomas of
all kinds, including one or more specific types of cancer, e.g., a
lung cancer, breast cancer, an alimentary or gastrointestinal tract
cancer such as colon, esophageal and pancreatic cancer, a liver
cancer, a skin cancer, an ovarian cancer, an endometrial cancer, a
prostate cancer, a lymphoma, hematopoietic tumors, such as a
leukemia, a kidney cancer, a bronchial cancer, a muscle cancer, a
bone cancer, a bladder cancer or a brain cancer, such as
astrocytoma, anaplastic astrocytoma, glioblastoma, medulloblastoma,
and neuroblastoma and their metastases. Suitable pre-malignant
lesions to be detected or monitored using the invention include,
but are not limited to, lobular carcinoma in situ and ductal
carcinoma in situ.
The invention methods can be used to assay the DNA of any mammalian
subject, including, but not limited to, humans, pet (e.g., dogs,
cats, ferrets) and farm animals (meat and dairy).
The invention features in certain aspects a method for identifying
metastases in a subject comprising detecting nucleic acid
hypermethylation of one or more genes in one or more samples,
wherein detecting nucleic acid hypermethylation identifies
metastases. The term "hypermethylation" as used herein refers to
the presence of methylated alleles in one or more nucleic acids. In
preferred embodiments, hypermethylation is detected using
methylation specific polymerase chain reaction (MSP).
The samples, in certain embodiments, can be from tumor tissue,
lymph nodes, bone marrow or blood. Thus, the invention can be used
to identify metastases in a subject comprising detecting nucleic
acid hypermethylation of one or more genes in tumor tissues or in
lymph nodes, wherein detecting nucleic acid hypermethylation
identifies metastases. Hypermethylation can be detected in tumor
tissue alone, e.g. primary tumor tissue, or tumor tissue and lymph
nodes. In certain preferred embodiments, detection of
hypermethylation in the lymph nodes indicates an early recurring
disease. In other certain preferred embodiments, detection of
hypermethylation in the lymph nodes indicates a more aggressive
disease. Often, an early recurring disease is a more aggressive
disease although the two are not mutually exclusive.
In other aspects, the invention features a method for identifying
micrometastases in a subject comprising detecting nucleic acid
hypermethylation of one or more genes in tumor tissue or lymph
node, wherein the genes are selected from the group consisting of:
genes involved in tumor suppression, DNA repair, apoptosis,
anti-proliferation, ras signaling, adhesion, differentiation,
development, and cell cycle regulation, in one or more cells or
tissues, wherein detecting nucleic acid hypermethylation identifies
micrometastases.
In other examples, the invention as described herein features a
method for identifying micrometastases in a subject comprising
detecting nucleic acid hypermethylation of at least one or more
genes in a sample comprising tumor and lymph nodes, where the
sample genes are selected from genes involved in tumor suppression,
nucleic acid repair, apoptosis, anti-proliferation, ras signaling,
adhesion, differentiation, development, and cell cycle regulation,
in one or more cells or tissues, and where detecting nucleic acid
methylation identifies micrometastases.
In practice, the method for detecting or diagnosing a proliferative
disease in a subject comprises, in certain embodiments, extracting
nucleic acid from one or more cell or tissue samples, detecting
nucleic acid hypermethylation of one or more genes in the sample;
and identifying the nucleic acid hypermethylation state of one or
more genes, wherein nucleic acid hypermethylation of genes
indicates a proliferative disease. In preferred examples, the
proliferative disease is cancer.
As described herein, in certain preferred examples, the one or more
genes comprise one or more CpG islands in the promoter regions.
Accordingly, any gene that contains one or more CpG island in the
promoter region is suitable for use in the methods of the
invention; however in certain preferred examples, the one or more
genes may be selected from any of p-16, H-cadherin, APC, RASSF1A,
MGMT, DAPK, or ASC, and as described in SEQ ID NOs 1-7.
In certain embodiments, hypermethylation of at least one of the
genes is detected. In other certain embodiments, hypermethylation
of at least two of the genes is detected. In other certain
embodiments, hypermethylation of at least three of the genes is
detected.
The detection of metastases as described in these methods can be
used to detect or diagnose a proliferative disease.
The detection of metastases as described in these methods can be
used after surgery or therapy to treat a proliferative disease.
The detection of metastases as described in these methods can be
used to predict the recurrence of a proliferative disease.
The detection of metastases as described in these methods can be
used to stage a proliferative disease.
The detection of metastases as described in these methods can be
used to determine a course of treatment for a subject.
These embodiments are discussed in further detail herein.
Methods of Treatment
The invention as described herein can be used to treat a subject
having or at risk for having a proliferative disease, such as
cancer. Accordingly, the method comprises identifying nucleic acid
hypermethylation of one or more genes, where nucleic acid
hypermethylation indicates having or a risk for having a
proliferative disease, and administering to the subject a
therapeutically effective amount of a demethylating agent, thereby
treating a subject having or at risk for having a proliferative
disease.
The method can be used in combination with one or more
chemotherapeutic agents. Anti-cancer drugs that may be used in the
various embodiments of the invention, including pharmaceutical
compositions and dosage forms and kits of the invention, include,
but are not limited to: acivicin; aclarubicin; acodazole
hydrochloride; acronine; adozelesin; aldesleukin; altretamine;
ambomycin; ametantrone acetate; aminoglutethimide; amsacrine;
anastrozole; anthramycin; asparaginase; asperlin; azacitidine;
azetepa; azotomycin; batimastat; benzodepa; bicalutamide;
bisantrene hydrochloride; bisnafide dimesylate; bizelesin;
bleomycin sulfate; brequinar sodium; bropirimine; busulfan;
cactinomycin; calusterone; caracemide; carbetimer; carboplatin;
carmustine; carubicin hydrochloride; carzelesin; cedefingol;
chlorambucil; cirolemycin; cisplatin; cladribine; crisnatol
mesylate; cyclophosphamide; cytarabine; dacarbazine; dactinomycin;
daunorubicin hydrochloride; decitabine; dexormaplatin; dezaguanine;
dezaguanine mesylate; diaziquone; docetaxel; doxorubicin;
doxorubicin hydrochloride; droloxifene; droloxifene citrate;
dromostanolone propionate; duazomycin; edatrexate; eflornithine
hydrochloride; elsamitrucin; enloplatin; enpromate; epipropidine;
epirubicin hydrochloride; erbulozole; esorubicin hydrochloride;
estramustine; estramustine phosphate sodium; etanidazole;
etoposide; etoposide phosphate; etoprine; fadrozole hydrochloride;
fazarabine; fenretinide; floxuridine; fludarabine phosphate;
fluorouracil; flurocitabine; fosquidone; fostriecin sodium;
gemcitabine; gemcitabine hydrochloride; hydroxyurea; idarubicin
hydrochloride; ifosfamide; ilmofosine; interleukin II (including
recombinant interleukin II, or rIL2), interferon alfa-2a;
interferon alfa-2b; interferon alfa-n1; interferon alfa-n3;
interferon beta-I a; interferon gamma-I b; iproplatin; irinotecan
hydrochloride; lanreotide acetate; letrozole; leuprolide acetate;
liarozole hydrochloride; lometrexol sodium; lomustine; losoxantrone
hydrochloride; masoprocol; maytansine; mechlorethamine,
mechlorethamine oxide hydrochloride rethamine hydrochloride;
megestrol acetate; melengestrol acetate; melphalan; menogaril;
mercaptopurine; methotrexate; methotrexate sodium; metoprine;
meturedepa; mitindomide; mitocarcin; mitocromin; mitogillin;
mitomalcin; mitomycin; mitosper; mitotane; mitoxantrone
hydrochloride; mycophenolic acid; nocodazole; nogalamycin;
ormaplatin; oxisuran; paclitaxel; pegaspargase; peliomycin;
pentamustine; peplomycin sulfate; perfosfamide; pipobroman;
piposulfan; piroxantrone hydrochloride; plicamycin; plomestane;
porfimer sodium; porfiromycin; prednimustine; procarbazine
hydrochloride; puromycin; puromycin hydrochloride; pyrazofurin;
riboprine; rogletimide; safingol; safingol hydrochloride;
semustine; simtrazene; sparfosate sodium; sparsomycin;
spirogermanium hydrochloride; spiromustine; spiroplatin;
streptonigrin; streptozocin; sulofenur; talisomycin; tecogalan
sodium; tegafur; teloxantrone hydrochloride; temoporfin;
teniposide; teroxirone; testolactone; thiamiprine; thioguanine;
thiotepa; tiazofurin; tirapazamine; toremifene citrate; trestolone
acetate; triciribine phosphate; trimetrexate; trimetrexate
glucuronate; triptorelin; tubulozole hydrochloride; uracil mustard;
uredepa; vapreotide; verteporfin; vinblastine sulfate; vincristine
sulfate; vindesine; vindesine sulfate; vinepidine sulfate;
vinglycinate sulfate; vinleurosine sulfate; vinorelbine tartrate;
vinrosidine sulfate; vinzolidine sulfate; vorozole; zeniplatin;
zinostatin; zorubicin hydrochloride, improsulfan, benzodepa,
carboquone, triethylenemelamine, triethylenephosphoramide,
triethylenethiophosphoramide, trimethylolomelamine, chlornaphazine,
novembichin, phenesterine, trofosfamide, estermustine,
chlorozotocin, gemzar, nimustine, ranimustine, dacarbazine,
mannomustine, mitobronitol, aclacinomycins, actinomycin F(1),
azaserine, bleomycin, carubicin, carzinophilin, chromomycin,
daunorubicin, daunomycin, 6-diazo-5-oxo-1-norleucine, doxorubicin,
olivomycin, plicamycin, porfiromycin, puromycin, tubercidin,
zorubicin, denopterin, pteropterin, 6-mercaptopurine, ancitabine,
6-azauridine, carmofur, cytarabine, dideoxyuridine, enocitabine,
pulmozyme, aceglatone, aldophosphamide glycoside, bestrabucil,
defofamide, demecolcine, elfornithine, elliptinium acetate,
etoglucid, flutamide, hydroxyurea, lentinan, phenamet,
podophyllinic acid, 2-ethylhydrazide, razoxane, spirogermanium,
tamoxifen, taxotere, tenuazonic acid, triaziquone,
2,2',2''-trichlorotriethylamine, urethan, vinblastine, vincristine,
vindesine and related agents. 20-epi-1,25 dihydroxyvitamin D3;
5-ethynyluracil; abiraterone; aclarubicin; acylfulvene; adecypenol;
adozelesin; aldesleukin; ALL-TK antagonists; altretamine;
ambamustine; amidox; amifostine; aminolevulinic acid; amrubicin;
amsacrine; anagrelide; anastrozole; andrographolide; angiogenesis
inhibitors; antagonist D; antagonist G; antarelix; anti-dorsalizing
morphogenetic protein-1; antiandrogen, prostatic carcinoma;
antiestrogen; antineoplaston; antisense oligonucleotides;
aphidicolin glycinate; apoptosis gene modulators; apoptosis
regulators; apurinic acid; ara-CDP-DL-PTBA; arginine deaminase;
asulacrine; atamestane; atrimustine; axinastatin 1; axinastatin 2;
axinastatin 3; azasetron; azatoxin; azatyrosine; baccatin III
derivatives; balanol; batimastat; BCR/ABL antagonists;
benzochlorins; benzoylstaurosporine; beta lactam derivatives;
beta-alethine; betaclamycin B; betulinic acid; bFGF inhibitor;
bicalutamide; bisantrene; bisaziridinylspermine; bisnafide;
bistratene A; bizelesin; breflate; bropirimine; budotitane;
buthionine sulfoximine; calcipotriol; calphostin C; camptothecin
derivatives; canarypox IL-2; capecitabine;
carboxamide-amino-triazole; carboxyamidotriazole; CaRest M3; CARN
700; cartilage derived inhibitor; carzelesin; casein kinase
inhibitors (ICOS); castanospermine; cecropin B; cetrorelix;
chlorins; chloroquinoxaline sulfonamide; cicaprost; cisporphyrin;
cladribine; clomifene analogues; clotrimazole; collismycin A;
collismycin B; combretastatin A4; combretastatin analogue;
conagenin; crambescidin 816; crisnatol; cryptophycin 8;
cryptophycin A derivatives; curacin A; cyclopentanthraquinones;
cycloplatam; cypemycin; cytarabine ocfosfate; cytolytic factor;
cytostatin; dacliximab; decitabine; dehydrodidemnin B; deslorelin;
dexamethasone; dexifosfamide; dexrazoxane; dexverapamil;
diaziquone; didemnin B; didox; diethylnorspermine;
dihydro-5-azacytidine; dihydrotaxol, 9-; dioxamycin; diphenyl
spiromustine; docetaxel; docosanol; dolasetron; doxifluridine;
droloxifene; dronabinol; duocarmycin SA; ebselen; ecomustine;
edelfosine; edrecolomab; eflornithine; elemene; emitefur;
epirubicin; epristeride; estramustine analogue; estrogen agonists;
estrogen antagonists; etanidazole; etoposide phosphate; exemestane;
fadrozole; fazarabine; fenretinide; filgrastim; finasteride;
flavopiridol; flezelastine; fluasterone; fludarabine;
fluorodaunorunicin hydrochloride; forfenimex; formestane;
fostriecin; fotemustine; gadolinium texaphyrin; gallium nitrate;
galocitabine; ganirelix; gelatinase inhibitors; gemcitabine;
glutathione inhibitors; hepsulfam; heregulin; hexamethylene
bisacetamide; hypericin; ibandronic acid; idarubicin; idoxifene;
idramantone; ilmofosine; ilomastat; imidazoacridones; imiquimod;
immunostimulant peptides; insulin-like growth factor-1 receptor
inhibitor; interferon agonists; interferons; interleukins;
iobenguane; iododoxorubicin; ipomeanol, 4-; iroplact; irsogladine;
isobengazole; isohomohalicondrin B; itasetron; jasplakinolide;
kahalalide F; lamellarin-N triacetate; lanreotide; leinamycin;
lenograstim; lentinan sulfate; leptolstatin; letrozole; leukemia
inhibiting factor; leukocyte alpha interferon;
leuprolide+estrogen+progesterone; leuprorelin; levamisole;
liarozole; linear polyamine analogue; lipophilic disaccharide
peptide; lipophilic platinum compounds; lissoclinamide 7;
lobaplatin; lombricine; lometrexol; lonidamine; losoxantrone;
lovastatin; loxoribine; lurtotecan; lutetium texaphyrin;
lysofylline; lytic peptides; maitansine; mannostatin A; marimastat;
masoprocol; maspin; matrilysin inhibitors; matrix metalloproteinase
inhibitors; menogaril; merbarone; meterelin; methioninase;
metoclopramide; MIF inhibitor; mifepristone; miltefosine;
mirimostim; mismatched double stranded RNA; mitoguazone;
mitolactol; mitomycin analogues; mitonafide; mitotoxin fibroblast
growth factor-saporin; mitoxantrone; mofarotene; molgramostim;
monoclonal antibody, human chorionic gonadotrophin; monophosphoryl
lipid A+myobacterium cell wall sk; mopidamol; multiple drug
resistance gene inhibitor; multiple tumor suppressor 1-based
therapy; mustard anticancer agent; mycaperoxide B; mycobacterial
cell wall extract; myriaporone; N-acetyldinaline; N-substituted
benzamides; nafarelin; nagrestip; naloxone+pentazocine; napavin;
naphterpin; nartograstim; nedaplatin; nemorubicin; neridronic acid;
neutral endopeptidase; nilutamide; nisamycin; nitric oxide
modulators; nitroxide antioxidant; nitrullyn; O6-benzylguanine;
octreotide; okicenone; oligonucleotides; onapristone; ondansetron;
ondansetron; oracin; oral cytokine inducer; ormaplatin; osaterone;
oxaliplatin; oxaunomycin; taxel; taxel analogues; taxel
derivatives; palauamine; palmitoylrhizoxin; pamidronic acid;
panaxytriol; panomifene; parabactin; pazelliptine; pegaspargase;
peldesine; pentosan polysulfate sodium; pentostatin; pentrozole;
perflubron; perfosfamide; perillyl alcohol; phenazinomycin;
phenylacetate; phosphatase inhibitors; picibanil; pilocarpine
hydrochloride; pirarubicin; piritrexim; placetin A; placetin B;
plasminogen activator inhibitor; platinum complex; platinum
compounds; platinum-triamine complex; porfimer sodium;
porfiromycin; prednisone; propyl bis-acridone; prostaglandin J2;
proteasome inhibitors; protein A-based immune modulator; protein
kinase C inhibitor; protein kinase C inhibitors, microalgal;
protein tyrosine phosphatase inhibitors; purine nucleoside
phosphorylase inhibitors; purpurins; pyrazoloacridine;
pyridoxylated hemoglobin polyoxyethylene conjugate; raf
antagonists; raltitrexed; ramosetron; ras farnesyl protein
transferase inhibitors; ras inhibitors; ras-GAP inhibitor;
retelliptine demethylated; rhenium Re 186 etidronate; rhizoxin;
ribozymes; RII retinamide; rogletimide; rohitukine; romurtide;
roquinimex; rubiginone B1; ruboxyl; safingol; saintopin; SarCNU;
sarcophytol A; sargramostim; Sdi 1 mimetics; semustine; senescence
derived inhibitor 1; sense oligonucleotides; signal transduction
inhibitors; signal transduction modulators; single chain antigen
binding protein; sizofiran; sobuzoxane; sodium borocaptate; sodium
phenylacetate; solverol; somatomedin binding protein; sonermin;
sparfosic acid; spicamycin D; spiromustine; splenopentin;
spongistatin 1; squalamine; stem cell inhibitor; stem-cell division
inhibitors; stipiamide; stromelysin inhibitors; sulfinosine;
superactive vasoactive intestinal peptide antagonist; suradista;
suramin; swainsonine; synthetic glycosaminoglycans; tallimustine;
tamoxifen methiodide; tauromustine; tazarotene; tecogalan sodium;
tegafur; tellurapyrylium; telomerase inhibitors; temoporfin;
temozolomide; teniposide; tetrachlorodecaoxide; tetrazomine;
thaliblastine; thiocoraline; thrombopoietin; thrombopoietin
mimetic; thymalfasin; thymopoietin receptor agonist; thymotrinan;
thyroid stimulating hormone; tin ethyl etiopurpurin; tirapazamine;
titanocene bichloride; topsentin; toremifene; totipotent stem cell
factor; translation inhibitors; tretinoin; triacetyluridine;
triciribine; trimetrexate; triptorelin; tropisetron; turosteride;
tyrosine kinase inhibitors; tyrphostins; UBC inhibitors; ubenimex;
urogenital sinus-derived growth inhibitory factor; urokinase
receptor antagonists; vapreotide; variolin B; vector system,
erythrocyte gene therapy; velaresol; veramine; verdins;
verteporfin; vinorelbine; vinxaltine; vitaxin; vorozole;
zanoterone; zeniplatin; zilascorb; and zinostatin stimalamer.
Preferred additional anti-cancer drugs are 5-fluorouracil and
leucovorin. Additional cancer therapeutics include monoclonal
antibodies such as rituximab, trastuzumab and cetuximab.
Demethylating Agents
In certain embodiments, the invention features methods of
identifying an agent that de-methylates hypermethylated nucleic
acids comprising identifying one or more cell or tissue samples
with hypermethylated nucleic acid, extracting the hypermethylated
nucleic acid, contacting the nucleic acid with one or more nucleic
acid de-methylating candidate agents and a control agent, and
identifying the nucleic acid hypermethylation state, wherein
nucleic acid de-methylation of genes in the sample by the candidate
agent compared to the control indicates a demethylating agent,
thereby identifying an agent that de-methylates hypermethylated
nucleic acid.
III. Methods of Predicting Disease Recurrence
In other certain aspects, the invention features methods for
predicting the recurrence of proliferative diseases, e.g.
cancer.
Accordingly, the invention features methods for predicting the
recurrence of a proliferative disease in a subject comprising
detecting nucleic acid hypermethylation of one or more genes
wherein detecting nucleic acid hypermethylation of one or more
genes is a predictor of the recurrence of a proliferative
disease.
In certain preferred embodiments, the method comprises extracting
nucleic acid from one or more cell or tissue samples, detecting
nucleic acid hypermethylation of one or more genes in the sample,
and identifying the nucleic acid hypermethylation state of one or
more genes, wherein nucleic acid hypermethylation of genes is
indicative of the recurrence of a proliferative disease.
In certain cases, the rate of recurrence of a proliferative disease
can be correlated with the detection of hypermethylation in a cell
or tissue sample. In certain embodiments, the cell or tissue sample
is tumor tissue or lymph node. In exemplary embodiments, the rate
of recurrence of a proliferative disease is more rapid when gene
hypermethylation is detected in lymph node. For example, when gene
hypermethylation (e.g. p16 or H-cadherin) is detected the primary
tumor, the odds of recurrence may be less than when the same genes
are hypermethylated in N1 lymph nodes. Moreover, if the same genes
(e.g. p16 or H-cadherin) were examined for hypermethylation in the
mediastinal lymph nodes, the odds of recurrence may be the greatest
compared to the former tissues (primary tumor and N1 lymph
nodes).
The discovery and clinical validation of markers for cancer of all
types which can predict prognosis, likelihood of invasive or
metastatic spread is one of the major challenges facing in the
field of oncology today. Adjuvant and neoadjuvant therapy (e.g.
chemotherapy) are promising treatment modalities, however although
adjuvant chemotherapy has been demonstrated to improve survival,
for example in node negative breast cancer patients (43), problems
remain, for example in the uncertainty as to how to best identify
patients whose risk of disease recurrence exceeds their risk of
significant therapeutic toxicity. Thus, a need remains for methods
for that enable clinical decisions on adjuvant and neoadjuvant
therapy, tumor surveillance and the likelihood of disease
progression based on validated tumor markers correlated with
metastasis and recurrence.
In other certain aspects, the invention features a method for
determining the prognosis of a subject suffering from a
proliferative disease comprising: detecting nucleic acid
hypermethylation of one or more genes wherein the detection of
nucleic acid hypermethylation is used for determining the prognosis
of a subject suffering from a proliferative disease.
The prognosis can be used by the clinician to determine the course
of treatment, and to monitor the course of treatment. As is
understood by the skilled practicioner, prognosis is a prediction
and can change during the course of treatment.
IV. Methods of Staging
The methods of the invention as described herein are used in
exemplary embodiments to stage or re-stage a proliferative disease,
e.g. a neoplasia or cancer.
Staging can refer to "clinical" staging or "molecular" staging.
Clinical staging describes the extent or severity of an
individual's cancer based on the extent of the original (primary)
tumor and the extent of spread in the body. Typically, clinical
staging is used in determining a subject's course of treatment and
to estimate the subject's prognosis.
The TNM system is one of the most commonly used staging systems.
The formal TNM staging system, promulgated by the American Joint
Committee on Cancer (AJCC), is based almost exclusively on the
anatomical extent of disease, which is assessed using a combination
of tumor size or depth (T), lymph node spread (N), and presence or
absence of metastases (M). Since its inception in 1958, the TNM
system has provided a standardized, anatomical basis for staging
with several important functions. It provides a basis for
prediction of survival, choice of initial treatment, stratification
of patients in clinical trials, accurate communication among
healthcare providers, and uniform reporting of outcomes. For most
tumor types, disease burden and spread have been considered the
most reliable predictors of survival and determinants of the type
and intensity of therapy to be used. Less often, tumor grade,
histological subtype or patient age has been added to tnm staging
when the ajcc became convinced that such information would
significantly improve the prediction of survival or response to
therapy. In the TMJ system, a number is added to each letter to
indicate the size or extent of the tumor and the extent of spread.
In a primary tumor (T), the designation tx indicates that the
primary tumor cannot be evaluated, T0 indicates no evidence of
primary tumor, tis indicates carcinoma in situ (early cancer that
has not spread to neighboring tissue) and T1, T2, T3, T4 indicates
size and/or extent of the primary tumor. In the regional lymph
nodes (N), NX indicates the regional lymph nodes cannot be
evaluated, NO indicates there is no regional lymph node involvement
(no cancer found in the lymph nodes) and N1, N2, N3 indicates the
involvement of regional lymph nodes (number and/or extent of
spread). For distant metastasis (M), the designation MX indicates
that distant metastasis cannot be evaluated, m0 indicates no
distant metastasis (cancer has not spread to other parts of the
body), M1 indicates distant metastasis (cancer has spread to
distant parts of the body). Criteria for stages differ for
different types of cancer. More information on clinical staging can
be found on the world wide web, for example at
(www)cancer.gov/cancertopics/factsheet/detection/staging.
The instant invention provides the incorporation of biomarkers into
TNM staging. The instant invention provides a method of molecular
staging and re-staging by determining the nucleic acid
hypermethylation of one or more certain genes. The invention
provides methods of molecular restaging that can be used to
re-stage any cancer with metastatic capability. In preferred
embodiments, hypermethylated nucleic acids are detected in the
lymph nodes. By molecular staging and re-staging through the
detection of hypermethylated nucleic acids in the lymph nodes, the
invention provides methods of detection of early recurrence of
proliferative disease, e.g. cancer, that are unable to be detected
by methods of clinical staging.
For example, in certain embodiments, molecular re-staging can
detect hypermethylation in lymph nodes that are have a clinical
designation of N=x, meaning that there is no clinical detection of
cancer in the lymph nodes.
Accordingly, molecular re-staging as described herein can predict
early recurrence of cancer, and thereby detect aggressive cancers
at an earlier stage in their progression.
In preferred aspects, the invention features a method for staging
or re-staging a proliferative disease in a subject comprising
detecting nucleic acid hypermethylation of one or more genes
wherein detecting nucleic acid hypermethylation is used for staging
a proliferative disease. In certain examples, the stage of
proliferative disease is predictive of disease recurrence.
Determining the stage of a proliferative disease can be used by the
clinician to determine the course of treatment. The terms "treat,"
treating," "treatment," and the like are meant to refer to reducing
or ameliorating a disorder and/or symptoms associated therewith. It
will be appreciated that, although not precluded, treating a
disorder or condition does not require that the disorder, condition
or symptoms associated therewith be completely eliminated. In
certain cases, an early recurring cancer may be treated with more
aggressive therapy. The term "aggressive treatment regimen" is
intended to mean reducing or ameliorating a disorder and/or
symptoms associated therewith with a method of treatment (e.g.
combination of chemotherapeutic agents) more intensive or
comprehensive than usual, for instance in dosage or extent. It will
be appreciated that, although not precluded, aggressively treating
a disorder or condition does not require that the disorder,
condition or symptoms associated therewith be completely
eliminated.
The invention also features a method for staging or re-staging a
proliferative disease in a subject comprising extracting nucleic
acid from one or more cell or tissue samples, detecting nucleic
acid hypermethylation of one or more genes in the sample; and
identifying the nucleic acid hypermethylation state of one or more
genes, wherein nucleic acid hypermethylation of genes is used for
staging or re-staging of a proliferative disease.
Any tissue sample is suitable for use in the methods of staging or
re-staging. In preferred examples, the tissue samples are selected
from tumor, lymph node, bone marrow or blood or a combination
thereof. In certain preferred examples, the samples are from the
lymph nodes.
The molecular grading methods as described herein cab be performed
prior to or after therapeutic intervention for the proliferative
disease, e.g. cancer. The therapeutic intervention can be selected
from treatment with an agent or can be a surgical procedure. In
this way, the methods for staging or re-staging a proliferative
disease in a subject comprising detecting nucleic acid
hypermethylation of one or more genes as described herein can be
used as adjuvant or neoadjuvant therapy.
V. Samples
Samples for use in the methods of the invention include cells or
tissues obtained from any solid tumor, samples taken from lymph
nodes, from bone marrow or from blood. Additionally, the sample may
be a sample that is taken from plasma, serum, sputum, or other
fluid. Tumor DNA can be found in various body fluids and these
fluids can potentially serve as diagnostic material.
Any nucleic acid specimen, in purified or nonpurified form, can be
utilized as the starting nucleic acid or acids, provided it
contains, or is suspected of containing, the specific nucleic acid
sequence containing the target locus (e.g., CpG). Thus, the process
may employ, for example, DNA or RNA, including messenger RNA,
wherein DNA or RNA may be single stranded or double stranded. In
the event that RNA is to be used as a template, enzymes, and/or
conditions optimal for reverse transcribing the template to DNA
would be utilized. In addition, a DNA-RNA hybrid which contains one
strand of each may be utilized. A mixture of nucleic acids may also
be employed, or the nucleic acids produced in a previous
amplification reaction herein, using the same or different primers
may be so utilized. The specific nucleic acid sequence to be
amplified, i.e., the target locus, may be a fraction of a larger
molecule or can be present initially as a discrete molecule, so
that the specific sequence constitutes the entire nucleic acid. It
is not necessary that the sequence to be amplified be present
initially in a pure form; it may be a minor fraction of a complex
mixture, such as contained in whole human DNA.
The nucleic acid-containing sample or specimen used for detection
of methylated CpG may be from any solid tumor or any source
including brain, colon, urogenital, hematopoietic, thymus, testis,
ovarian, uterine, prostate, breast, colon, lung and renal tissue
and may be extracted by a variety of techniques such as that
described by Maniatis, et al. (Molecular Cloning: A Laboratory
Manual, Cold Spring Harbor, N.Y., pp 280, 281, 1982).
If the extracted sample is impure (e.g., plasma, serum, stool,
ejaculate, sputum, saliva, ductal cells, nipple aspiration fluid,
ductal lavage fluid, cerebrospinal fluid or blood or a sample
embedded in parrafin), it may be treated before amplification with
an amount of a reagent effective to open the cells, fluids,
tissues, or animal cell membranes of the sample, and to expose
and/or separate the strand(s) of the nucleic acid(s). This lysing
and nucleic acid denaturing step to expose and separate the strands
will allow amplification to occur much more readily
Preferably, the method of amplifying is by PCR, as described herein
and as is commonly used by those of ordinary skill in the art.
However, alternative methods of amplification have been described
and can also be employed. PCR techniques and many variations of PCR
are known. Basic PCR techniques are described by Saiki et al. (1988
Science 239:487-491) and by U.S. Pat. Nos. 4,683,195, 4,683,202 and
4,800,159, each of which is incorporated herein by reference.
The conditions generally required for PCR include temperature,
salt, cation, pH and related conditions needed for efficient
copying of the master-cut fragment. PCR conditions include repeated
cycles of heat denaturation (i.e. heating to at least about
95.degree. C.) and incubation at a temperature permitting primer:
adaptor hybridization and copying of the master-cut DNA fragment by
the amplification enzyme. Heat stable amplification enzymes like
the pwo, Thermus aquaticus or Thermococcus litoralis DNA
polymerases which eliminate the need to add enzyme after each
denaturation cycle, are commercially available. The salt, cation,
pH and related factors needed for enzymatic amplification activity
are available from commercial manufacturers of amplification
enzymes.
As provided herein an amplification enzyme is any enzyme which can
be used for in vitro nucleic acid amplification, e.g. by the
above-described procedures. Such amplification enzymes include pwo,
Escherichia coli DNA polymerase I, Klenow fragment of E. coli
polymerase I, T4 DNA polymerase, T7 DNA polymerase, Thermus
aquaticus (Taq) DNA polymerase, Thermococcus litoralis DNA
polymerase, SP6 RNA polymerase, T7 RNA polymerase, T3 RNA
polymerase, T4 polynucleotide kinase, Avian Myeloblastosis Virus
reverse transcriptase, Moloney Murine Leukemia Virus reverse
transcriptase, T4 DNA ligase, E. coli DNA ligase or Q.beta.
replicase. Preferred amplification enzymes are the pwo and Taq
polymerases. The pwo enzyme is especially preferred because of its
fidelity in replicating DNA.
Once amplified, the nucleic acid can be attached to a solid
support, such as a membrane, and can be hybridized with any probe
of interest, to detect any nucleic acid sequence. Several membranes
are known to one of skill in the art for the adhesion of nucleic
acid sequences. Specific non-limiting examples of these membranes
include nitrocellulose (NITROPURE.RTM.) or other membranes used in
for detection of gene expression such as polyvinylchloride,
diazotized paper and other commercially available membranes such as
GENESCREEN.RTM., ZETAPROBE.RTM. (Biorad), and NYTRAN.RTM. Methods
for attaching nucleic acids to these membranes are well known to
one of skill in the art. Alternatively, screening can be done in a
liquid phase.
In nucleic acid hybridization reactions, the conditions used to
achieve a particular level of stringency will vary, depending on
the nature of the nucleic acids being hybridized. For example, the
length, degree of complementarity, nucleotide sequence composition
(e.g., GC v. AT content), and nucleic acid type (e.g., RNA v. DNA)
of the hybridizing regions of the nucleic acids can be considered
in selecting hybridization conditions. An additional consideration
is whether one of the nucleic acids is immobilized, for example, on
a filter.
An example of progressively higher stringency conditions is as
follows: 2.times.SSC/0.1% SDS at about room temperature
(hybridization conditions); 0.2.times.SSC/0.1% SDS at about room
temperature (low stringency conditions); 0.2.times.SSC/0.1% SDS at
about 42.degree. C. (moderate stringency conditions); and
0.1.times.SSC at about 68.degree. C. (high stringency conditions).
Washing can be carried out using only one of these conditions,
e.g., high stringency conditions, or each of the conditions can be
used, e.g., for 10-15 minutes each, in the order listed above,
repeating any or all of the steps listed. However, as mentioned
above, optimal conditions will vary, depending on the particular
hybridization reaction involved, and can be determined empirically.
In general, conditions of high stringency are used for the
hybridization of the probe of interest.
The probe of interest can be detectably labeled, for example, with
a radioisotope, a fluorescent compound, a bioluminescent compound,
a chemiluminescent compound, a metal chelator, or an enzyme. Those
of ordinary skill in the art will know of other suitable labels for
binding to the probe, or will be able to ascertain such, using
routine experimentation.
VI. Kits
The methods of the invention are ideally suited for the preparation
of kits.
The invention features kits for identifying the nucleic acid
hypermethylation state of one or more genes comprising gene
specific primers for use in polymerase chain reaction (PCR), and
instructions for use.
The invention also features kits for detecting metastases by
detecting nucleic acid hypermethylation of one or more genes, the
kit comprising gene specific primers for use in polymerase chain
reaction (PCR), and instructions for use. In preferred embodiments,
the metastases are micrometastases.
As described above, the PCR, in particularly preferred examples, is
methylation specific PCR (MSP).
In certain embodiments, any gene comprising one or more CpG islands
in the promoter region can be detected using the kits of the
invention. In certain preferred examples, the one or more genes are
selected from the group consisting of genes involved in tumor
suppression, nucleic acid repair, anti-proliferation, apoptosis,
ras signaling, adhesion, differentiation, development, and cell
cycle regulation.
In certain preferred embodiments of the invention the genes can be
detected in a panel consisting of the following:
(1) genes involved in tumor suppression and cell adhesion
(2) genes involved in cell cycle regulation and adhesion
(3) genes involved in tumor suppression and cell cycle
regulation
(4) genes involved in ras signaling and cell cycle control
In certain examples, the genes are selected from the group
consisting of: p-16, H-cadherin, APC, RASSF1A, MGMT, DAPK, and
ASC
The kits can be used to detect hypermethylation of at least one of
the genes as described herein. In some examples, can be used to
detect hypermethylation of at least two of the genes as described
herein. In other examples, the kits can be used to detect
hypermethylation of at least three of the genes as described
herein.
The two genes can be selected from the following: p-16 and
H-cadherin, H-cadherin and APC, APC and p16, or RASSf1A and
p16.
Carrier means are suited for containing one or more container means
such as vials, tubes, and the like, each of the container means
comprising one of the separate elements to be used in the method.
In view of the description provided herein of invention methods,
those of skill in the art can readily determine the apportionment
of the necessary reagents among the container means. For example,
one of the container means can comprise a container containing gene
specific primers for use in polymerase chain reaction methods of
the invention. In addition, one or more container means can also be
included which comprise a methylation sensitive restriction
endonuclease.
The following examples are offered by way of illustration, not by
way of limitation. While specific examples have been provided, the
above description is illustrative and not restrictive. Any one or
more of the features of the previously described embodiments can be
combined in any manner with one or more features of any other
embodiments in the present invention. Furthermore, many variations
of the invention will become apparent to those skilled in the art
upon review of the specification. The scope of the invention
should, therefore, be determined not with reference to the above
description, but instead should be determined with reference to the
appended claims along with their full scope of equivalents.
EXAMPLES
In the examples provided herein, gene hypermethylation versus
traditional histopathology was tested to predict disease recurrence
in solid tumors. The examples presented herein show that gene
hypermethylation of not only the primary malignancy, but also lymph
nodes, may be used to restage and assess prognosis of patients with
stage I tumors, in particular examples patients with stage I NSCLC.
These markers are shown to also be potential targets for reversal
of gene silencing and may be important in adjuvant approaches to
reduce disease recurrence.
Example 1: Patient Characteristics
Cases and controls were similar with respect to clinical and
demographic variables, as shown in Table 1, below. By the American
Society of Anesthesia Physical Status Classification, both cases
and controls were equally fit for surgery. The most frequent site
of recurrence was the ipsilateral chest (45%) followed by
metastases to bone (14%), brain (12%) and mediastinum (12%).
Although 15% of controls underwent sublobar resections, all
pulmonary resections in controls were curative of cancer for the
study period.
TABLE-US-00015 TABLE 1 Characteristics of the patients (N = 187).
Recurrent Control Validation Group Group Group Characteristic (N =
51) (N = 116) (N = 20) Age - yr Median 64 67 66 Interquartile range
58-71 60-72 57-72 Sex - no. (%) Male 24 (47.1) 54 (46.6) 8 (40.0)
Female 27 (52.9) 62 (53.4) 12 (60.0) Race - no. (%) Caucasian 43
(84.3) 96 (82.7) 15 (75.0) African-American 6 (11.8) 19 (16.4) 5
(25.0) Other 2 (3.9) 1 (0.9) 0 (0.0) Stage - no. (%) 1A (T1N0) 26
(51.0) 75 (64.7) 9 (45.0) 1B (T2N0) 25 (49.0) 41 (35.3) 11 (56.0)
Tumor Size - no. (%) <3 cm 25 (49.0) 72 (62.1) 13 (65.0) >3
cm 26 (51.0) 44 (37.9) 7 (35.0) Surgical Procedure - no. (%)
Lobectomy 46 (90.2) 95 (81.9) 20 (100) Pnuemonoctomy/Bilobectomy 4
(7.8) 4 (3.4) 0 0.0 .sup. Sublobar Resections 1 (2.0) 17 (14.7) 0
0.0 .sup. Histology - no. (%) Adenocarcinoma* 30 (58.8) 62 (53.5)
15 (75.0) Squamous cell 15 (29.4) 42 (36.2) 4 (20.0) Other 6 (11.8)
12 (10.3) 1 (5.0) Grade - no. (%) Well Differentiated 5 (9.8) 10
(8.6) 2 (10.0) Moderately Differentiated 22 (43.1) 30 (25.9) 11
(55.0) Poorly Differentiated 20 (39.3) 45 (38.8) 7 (35.0) Unknown 4
(7.8) 31 (26.7) 0 (0.0) ASA Physical Status 3 3 3 Smoking - no. (%)
Ever 43 (84.3) 102 (87.9) 29 (100) Never 8 (15.7) 12 (10.4) 0 (0.0)
Unknown 0 (0.0) 2 (1.7) 0 (0.0) *Includes bronchioloalveolar
carcinoma and adeno-squamous histologies .sup..dagger.Other
includes large cell, basaloid, and mucoepidermoid. ASA--American
Society Anestesia Physical Status Classification Cases were matched
with controls. on age, sex, stage, and date of surgery
Example 2: Risk of Recurrence--Gene Methylation
Risk of Recurrence Using Clinical Predictors
The clinicopathologic covariates of pathologic stage, age, sex,
tumor histology, smoking, and race did not predict risk of disease
recurrence in NSCLC patients with histological negative lymph
nodes, as shown in Table 2, below. Pathologic tumor stage showed
the strongest risk for predicting disease recurrence independent of
other covariates, with patients with stage 1B disease (T2
malignancies .gtoreq.3 cm and/or visceral pleural invasion) having
a 1.71 (95% CI, 0.86-3.41) fold risk for disease recurrence
compared to patients with smaller sized tumors and no pleural
invasion (stage 1A).
TABLE-US-00016 TABLE 2 Supplemental Table 2. Crude and Adjusted
Odds Ratios (ORs) and 95% Confidence Limits for Risk of Recurrence
for Selected Demographic Characteristics. Characteristic Crude OR
95% CL Adjusted OR* 95% CL Stage 1A 1.00 -- 1.00 -- 1B 1.76
0.90-3.43 1.71 0.86-3.41 Age, continuous 0.98 0.94-1.01 0.97
0.94-1.01 Sex Female 1.00 -- 1.00 -- Male 1.02 0.53-1.97 0.98
0.49-1.96 Race Caucasian 1.00 -- 1.00 -- African American 0.89
0.36-2.19 0.84 0.33-2.12 Histology Adenocarcinoma 1.00 -- 1.00 --
Squamous cell 0.79 0.37-1.68 0.81 0.37-1.79 Other** 1.07 0.36-3.18
0.89 0.28-2.76 Smoking status Never 1.00 -- 1.00 -- Ever 0.63
0.24-1.66 0.72 0.26-1.99 *Multivariable logistic regression model
adjusted for stage (1A/1B), age (continuous), sex, race (C/AA),
histology (adenocarcinoma, squamous cell, other), smoking status
(ever/never)
Gene Methylation Predicts Risk of Recurrence in Tumor and Lymph
Nodes
Methylation profiles using 7 genes were obtained on 727 of 731
paraffin blocks corresponding to 167 patients. The prevalence for
methylation of four genes, p16, H-cadherin, RASSF1A and APC,
especially in tumors and/or N2 lymph nodes, differed between cases
and controls, as shown in Table 3.
TABLE-US-00017 TABLE 3 Table 2. Prevalence of Individual Gene
Hypermethylation in Tumor, N1, and N2 Lymph Nodes in Recurrent
Cases and Controls. (N = 167) Tumor Samples N1 Lymph Node Samples
N2 Lymph Node Samples Control Case Control Case Control Case (n =
104) (n = 50) (n = 82) (n = 41) (n = 56) (n = 34) Characteristics %
% p-value* % % p-value* % % p-value* MGMT 0.87 0.38 0.44 Methylated
36.1 34.7 29.5 37.5 35.8 44.1 ASC 0.65 0.81 0.91 Methylated 34.9
38.8 27.2 29.3 42.9 44.1 DAPK 0.93 0.91 0.41 Methylated 35.3 36.0
41.5 42.5 30.8 39.4 APC 0.81 0.48 0.06 Methylated 34.0 36.0 18.7
13.5 13.0 29.4 RASSF1A 0.10 0.61 0.15 Methylated 35.0 50.0 16.5
12.8 9.6 20.6 P16 <0.01 <0.01 <0.01 Methylated 26.0 52.0
13.7 35.0 16.7 48.5 H-Cadherin 0.04 0.12 0.04 Methylated 22.8 38.8
19.5 32.5 25.0 46.9 *Chi-squared test for homogeneity.
FIG. 1 shows multivariate logistic regression analysis that was
performed using the four genes that exhibited the largest
univariate distribution differences in methylation: p16,
H-cadherin, APC, and RASSF1A. The prognostic value of each
molecular variable was assessed in a model that adjusted for stage
(1A/1B), age (continuous), sex, race (Caucasian/African American),
histology (adenocarcinoma, squamous cell, other), smoking status
(ever/never) and then graphed as a Forest Plot. On the whole,
regardless of the genes considered, hypermethylation of the
mediastinal lymph node tissue had the highest prognostic value for
estimating lung cancer recurrence versus no methylation. As single
gene epigenetic markers, methylation of both p16 and H-cadherin had
robust odds ratios for recurrence for primary tumor, regional, and
mediastinal lymph nodes. Methylation of either RASSF1A or APC in
primary tumor or N2 nodes was also associated with a modest
elevation in odds of recurrence but this was not statistically
significant. If a patient with pathologic stage 1 disease (T1-2N0)
had concomitant methylation of p16 as well as H-cadherin in both
tumor and mediastinal lymph nodes, the estimated odds of lung
cancer recurrence was over 15 as compared to those patients without
concomitant methylation in these tissues. In particular, when
either p16 or H-cadherin was methylated in the primary tumor, the
adjusted odds of recurrence was 3.50 (95% CI, 1.65-7.41) and 2.12
(95% CI, 0.98-4.59), respectively (FIG. 1). When these same genes
were methylated in N1 lymph nodes, the odds of recurrence was 3.62
(95% CI, 1.41-9.32) and 1.99 (95% CI, 0.81-4.88), respectively. If
methylation of p16 or H-cadherin was observed in mediastinal lymph
nodes, the odds of recurrence was increased to 4.67 (95% CI,
1.52-14.4) and 3.98 (95% CI, 1.22-13.0) fold, respectively, as
shown in FIG. 1. Methylation of either RASSF1A or APC in primary
NSCLC or N2 nodes was also associated with a modest elevation in
risk for recurrence but this was not statistically significant
(FIG. 1).
Two gene combinations of methylation, for p16 and H-cadherin,
H-cadherin and APC, APC and p16, as well as RASSF1A and p16, all
were associated with increased risks of recurrence, especially in
either primary tumors or N2 nodes (FIG. 1). Concomitant methylation
of the best gene combination, p16 and H-cadherin, was significantly
associated with recurrent cancer in all three tissue types--primary
tumor, N1, as well as N2 lymph nodes. If a patient exhibited
methylation of p16 and H-cadherin in the primary tumor, the odds of
recurrence was eight times higher than if there was no methylation.
Even more striking, positive p16 and H-cadherin methylation in both
paired primary tumors and mediastinal lymph nodes denotes an
estimated odds of recurrent cancer of 15.5 (95% CI, 1.61-185) (FIG.
1), with a positive predictive value of 86%.
The above findings were re-tested for methylation of the 4-gene
panel by assaying the methylation status of these genes in a
validation set. 162 separate samples were obtained, representing an
independent set of 20 stage 1 patients (11 cases and 9 controls)
resected at a later date at the Johns Hopkins Hospital ("the
institution"), as shown in Table 1, above.
FIG. 2 shows Kaplan-Meier Estimates of Recurrence-Free Survival of
Pathologic Stage 1 Lung Cancer Patients (n=167) at the Johns
Hopkins Hospital, according to the number of methylated genes in a
4-gene panel at the time of surgical resection. The Kaplan-Meier
estimates for time to recurrence indicate that for both tumor as
well as for regional (N1) and mediastinal (N2) lymph nodes, as the
number of methylated genes in the panel increases, there is a
significant reduction in the recurrence-free survival (Panels A-C,
E-G). Furthermore, if concomitant methylation of both tumor and
mediastinal lymph nodes versus little or no methylation is
considered (Panels D and H), the Kaplan-Meier estimates reflect the
recurrence-free survivals of patients with a clinically useful risk
classification system as determined by our epigenetic marker panel.
Patients without methylation of the gene combination p16 and
H-cadherin in both primary tumor and mediastinal lymph nodes have a
significantly improved 5 year recurrence-free period than those
with these genes methylated (64% vs. 14%, p<0.001, respectively,
Panel H). An independent cohort of 20 patients validated the above
findings as those with concomitant methylation of both tumor and
mediastinal lymph nodes in two or more genes had a shorter time to
recurrence than those with two or more genes unmethylated in these
tissues (Panel I). Similarly, concomitant methylation of p16 and
H-cadherin in tumors and N2 nodes resulted in a worse 5 year
disease-free recurrence than if no methylation of this gene
combination occurred (Panel J). In the combined original and
validation datasets (n=187), patients with 2 or more genes in tumor
and N2 nodes methylated also have a worse 5 year recurrence rate
than those with these genes unmethylated in both tissues (Panel K).
For both the original and validation patients with p16 and
H-cadherin measured, both genes methylated in the tumor and N2
nodes resulted in a significantly shorter time to recurrence than
if p16 and H-cadherin were unmethylated (Panel L). As was the case
with the original cohort, univariate and multivariate analysis
showed that methylation of the panel of genes in both tumor and
lymph nodes was more predictive of disease recurrence than any
clinical or pathological variable (FIG. 2: Panels I and J). In
particular, positive p16 and H-cadherin methylation in both paired
primary tumors and mediastinal lymph nodes occurred in 4 cases and
no controls yielding an infinite odds of recurrent disease
reflected in FIG. 2, Panel J. This finding strongly supports the
original finding of an elevated odds ratio for recurrence when p16
and H-cadherin methylation is found in these tissues (FIG. 1).
Moreover, the estimated odds of recurrent cancer for the original
and validation datasets combined, for this gene combination when
found in both tumor and N2 nodes, increased to 25.25 (95% CI,
2.53-252.35). This is shown in Table 4, below.
TABLE-US-00018 TABLE 4 Table 3. Multivariate Odds Ratios (OR) and
95% Confidence Limits (95% CL) for Estimation of Risk of Recurrance
by Methylation Status for Selected Gene Markers Original Original
and Validation (n = 167) (n = 187) Gene Marker OR 95% CL OR* 95% CL
Single Genes Unmethylated APC 1.00 referent 1.00 referent Tumor
0.95 0.45-2.04 1.31 0.67-2.58 N1 0.69 0.22-2.10 0.78 0.32-1.91 N2
2.26 0.66-7.71 1.87 0.65-5.56 Tumor and N2 2.37 0.52-10.83 2.00
0.55-7.33 RASSF1A Tumor 1.79 0.85-3.75 1.86 0.94-3.68 N1 0.71
0.23-2.20 0.82 0.31-2.15 N2 1.66 0.43-6.43 2.13 0.65-6.95 Tumor and
N2 0.66 0.11-3.88 0.97 0.23-3.98 P16 Tumor 3.50 1.55-7.41 3.55
1.77-7.13 N1 3.62 1.41-9.32 4.14 1.81-9.49 N2 4.67 1.53-14.42 5.09
1.95-13.18 Tumor and N2 5.23 1.33-20.46 8.41 2.42-29.20 HCAD Tumor
2.12 0.98-4.59 2.33 1.16-4.69 N1 1.99 0.81-4.88 2.67 1.25-5.93 N2
3.98 1.22-13.01 4.04 1.53-13.63 Tumor and N2 6.89 1.36-34.87 7.55
1.99-28.60 Gene Combinations APC & RASSF1A Tumor 1.88 0.74-4.78
2.25 1.02-5.00 N1 1.22 0.15-14.53 2.34 0.46-11.75 N2 -- -- 3.49
0.30-40.75 Tumor and N2** -- -- 2.37 0.17-33.12 APC & P16 Tumor
4.16 1.60-10.81 4.48 1.91-10.51 N1 2.59 0.34-19.74 2.43 0.59-9.94
N2 13.10 1.20-142.73 7.45 1.35-41.20 Tumor and N2 5.27 0.38-73.57
7.70 0.70-84.88 APC & HCAD Tumor 1.54 0.55-4.31 2.14 0.94-4.91
N1 2.24 0.41-12.22 3.30 0.88-12.40 N2 4.58 1.50-20.01 3.13
0.89-11.01 Tumor and N2 11.79 0.85-163.24 9.48 0.87-103.18 RASSF1A
& P16 Tumor 5.95 2.15-16.56 5.26 2.13-13.00 N1 1.07 0.15-7.56
1.92 0.39-9.45 N2 3.01 0.49-18.64 4.60 0.85-25.03 Tumor and N2 2.91
0.24-35.35 3.67 0.32-41.69 RASSF1A & HCAD Tumor 1.61 0.69-3.89
1.71 0.78-3.74 N1 0.49 0.09-2.63 0.88 0.25-3.04 N2 1.36 0.22-8.48
1.91 0.40-9.21 Tumor and N2 2.49 0.18-34.29 3.51 0.32-38.57 P16
& HCAD Tumor 8.00 2.50-25.51 6.71 2.50-18.00 N1 4.08 1.06-15.70
6.13 1.99-18.89 N2 4.32 1.06-17.65 4.66 1.53-14.16 Tumor and N2
15.50 1.61-185.02 25.25 2.53-252.35 *Multivariate logistic
regression model adjusted for stage (1A/15) age (continuous), sex,
race (C/AA), histology (adenecarcinoma, squamous cell, other),
smoking status (ever/never). **No methylation in controls.
Example 3: Tumor Biology and Translational Implications
An observation is that, among those 51 patients in the cohort who
recurred, the presence of methylation in more than two genes in
paired primary tumors and mediastinal lymph nodes identifies those
who recur early versus those cases without markers that recur late
(9 months (range 5-30) vs. 25 months (range 6-40); p.ltoreq.0.04).
Thus, those who lack these epigenetic marks recur late and appear
to behave similarly to control patients who do not have recurrences
within the 40 month time frame studied, as is reflected in the
various risk for recurrence curves shown in FIG. 2.
Second, estimates of time to recurrence indicate that for both
cases and controls, as the number of methylated genes in the 4-gene
panel increases in primary tumor, regional and mediastinal lymph
nodes, there is a significant reduction in recurrence-free survival
(FIG. 2: Panels A-C, E-G). Moreover, if concomitant methylation of
both tumor and mediastinal lymph nodes is considered (Panels D and
H), the prognostic value of the epigenetic markers is further
increased. In Panels D and H, the recurrence estimates of the stage
1 subjects with .gtoreq.2 genes methylated reflect the historic
cancer-specific survivals of patients who would be pathologically
staged as stage 3 or higher (5). In the original cohort, those
patients with the combination of p16 and H-cadherin methylation in
tumor and mediastinal lymph nodes have a significantly reduced
5-year recurrence-free survival compared to those without
methylation (64% vs. 14%, p<0.001, respectively). This finding
also emerged in the small validation study of 20 patients as shown
in FIG. 2, panel J. Moreover, patients in the validation set with
.gtoreq.2 genes methylated in tumor and mediastinal lymph nodes
have significantly reduced 5-year recurrence-free survivals
compared to those without methylation (FIG. 2, panel I). Thus, when
the original and validation datasets are combined, the methylation
status for these parameters is now even more strongly prognostic of
disease-free survival (FIG. 2, panels K and L).
In the entire study population including the original and
validation patients, 91 individuals, 50 controls and 41 cases, had
p16 and H-cadherin methylation measured in both primary tumor and
N2 lymph nodes. Of those patients who were positive for both
markers in both sites, 10 of 11 were cases. All 10 had disease
recurrence within 30 months, 9 within 17 months, and 8 within a
year. Thus, the methylation status of p16 and H-cadherin in tumor
and N2 nodal DNA, appears to identify a subset, 25%, of stage 1
patients with a likelihood of rapid disease recurrence with a
positive predictive value of 91% and a specificity of 98%.
The results presented herein demonstrate two related features for
the detection of promoter region methylation in cancer. First, the
detection of promoter methylation within the resected primary tumor
for key genes can be associated with a more aggressive, recurrent
phenotype as has been shown in other settings (28,29). The loss of
function in key regulatory genes for cell cycle control (p16),
invasion and metastasis (H-Cadherin, APC), as well as Ras signaling
(RASSF1a) might be expected to result in a more aggressive primary
tumor. In addition, the ability to detect methylation within local
or regional nodes provides a second layer of information to this
subset identification, and demonstrates an additional approach for
detecting micrometastatic disease.
The data presented herein demonstrate that this approach may be
used to identify aggressive stage 1 lung cancer patients who were
not staged optimally by routine pathological analysis. The current
staging system for NSCLC is imprecise, and in stage 1 (T1-2N0)
disease, in particular, the clinicopathologic criteria understages
patients. The results presented herein show that gene promoter
methylation detection within NSCLC primary tumors can be used to
identify cells with high potential for metastatic spread, and also
to detect histologically occult micrometastases in lymph nodes used
to stage NSCLC. Although it is possible that the methylation
detected could represent free tumor DNA that has drained from the
primary tumor via lymphatics, this is unlikely, particularly for N2
nodes, since these are located distant from the lung in a separate
body compartment, the mediastinum. While the detection of
methylation of these genes in tumor or N1 nodes was often
associated with increased risk of recurrence, in the N2 lymph
nodes, especially, the markers were very strongly prognostic,
strengthening the contention that the DNA methylation is detecting
micrometastatic disease. This molecular distribution of markers in
patients with rapid recurrence mirrors the biological basis of
current histological staging systems that identify intact tumor
cells that have traversed the mediastinal pleura to the N2 nodes
and are associated with increased risk of recurrence.
The methods described herein present a molecular tool that
parallels the use of histologic examination in accepted clinical
pathology practice, but is more sensitive. This differs from
previous studies that have relied solely on molecular
characteristics of the primary malignancy (30-33). This ability to
utilize the predictive power inherent in identifying
micrometastases to lymph nodes may allow a more robust and reliable
molecular staging built upon tumor characteristics and the
detection of micrometastatic disease. Furthermore, recent promising
results from examining methylation changes in sputum for predicting
risk of lung cancer (34), or its recurrence (18), means the
detection of these changes could provide valuable pre-surgical
information as to disease stage and the metastatic potential of a
patient's tumor.
Methods
The invention was carried out using methods that include the
following.
Patients
Evidence for recurrent disease was evaluated on 715 pathologically
proven stage 1 (T1-2N0) patients diagnosed with non-small cell lung
carcinoma (NSCLC) (International Classification of Diseases-ninth
revision-Clinical Modification [ICD-9-CM] code 162.3-162.9) who
underwent lobectomy or greater resections at the Johns Hopkins
Hospital between Jan. 1, 1986 and Jul. 31, 2002. Only patients
followed for recurrent disease at the institution were eligible for
the analysis. The study cohort consisted of 71 patients (cases) who
despite receiving surgery with curative intent for pathological
stage 1 (T1-2N0) primary NSCLC, recurred at the institution within
40 months of surgery and died of their cancer. It was estimated
that by 40 months approximately 80% of patients with resected stage
1 lung cancer would recur. Using patient age, stage, date of
surgery (within 5 years), and sex, the cases were matched to 158
stage 1 patients (controls) from the remainder of the study
population. These 71 cases and 158 controls formed the basic
case-control population. From the above patients, samples were
gathered for methylation analysis for 51 cases and 116 matched
controls. Neither cases nor controls received adjuvant chemotherapy
since surgery was performed between 1986-2002 when guidelines did
not recommend adjuvant therapy for stage 1B patients (20, 21). All
patients were staged according to the new TNM classification
criteria (5), which include histological status of mediastinal
lymph nodes sampled from levels 2, 4, 7, 8, 9, and 10 on the right,
and 5, 6, 7, 8, 9 on the left side. Regional lymph nodes, confined
to the pleural space, were resected en bloc with the tumor.
Patients were excluded as cases if they had surgery involving less
than a lobectomy because there is strong evidence that patients
with such resections are at significantly increased risk of local
recurrence (22). Patients were also excluded as cases if they had
any macroscopic or microscopically positive surgical margins, or
underwent incomplete resection. In accord with this nested design,
seven individuals with recurrences after 40 months postoperatively
were considered as controls. The 20 patients in the validation set,
consisting of 11 cases and 9 matched controls, had 162 paraffin
blocks evaluated. All cases in the independent validation cohort,
except for two, underwent resection at our institution after August
2002. The study was approved by the Institutional Review Board of
the Johns Hopkins Medical Institutions.
Preparation of Tumor and Lymph Nodes
All specimens were labeled only with study-specific coded
identifiers to blind laboratory investigators as to case or control
status as well as to whether DNA samples came from tumor or lymph
nodes. DNA was extracted from three sequential 10 .mu.m sections
from unstained, paraffin embedded slides of resected tumors and
lymph nodes (both N1 and N2). For each sample, adjacent sections
were H&E stained for histological confirmation of either the
presence of malignancy for tumor samples, or the lack of neoplastic
cells for all lymph nodes. Tumor grading was at the time of
surgery. Unstained tissue sections were deparaffinized and DNA was
extracted as described previously 23. DNA was quantified
spectrophotometrically, and 1 .mu.g was denatured with sodium
hydroxide and modified with sodium bisulfite. Samples were then
purified with the Wizard DNA purification resin (Promega, Madison,
Wis.), treated again with sodium hydroxide, precipitated with
ethanol, and resuspended in water.
Methylation Specific PCR (MSP)
DNA methylation, for all lung cancer and lymph node DNA, was
determined by MSP performed by 3 individuals blinded to the results
of other investigators. Each individual extracted DNA and performed
all steps of the MSP reaction separately. There were 889 total
samples of tumor and lymph nodes examined. A multiplex-nested MSP
assay as previously described was used for all samples 24. The
nested approach amplifies bisulfite-modified DNA initially with
flanking PCR primers without preferentially amplifying methylated
or unmethylated DNA. The resulting fragment is then used as the
template for MSP. Primer sequences and conditions of p16, MGMT,
DAPK, RASSF1A, H-cadherin, ASC and APC have all been previously
described 16, 18, 24-26 including conditions optimized to achieve
specific detection of methylation in tumor but not in normal
lymphocytes, and are shown in Table 5, below (16, 18, 24-26).
TABLE-US-00019 TABLE 5 Supplemental Table 1: METHYLATED SPECIFIC
PCR CONDITIONS USED FRANK PCR for APC, MGMT, ASC, P16, DARK,
H-CADHERIN, RASSF1A: Using 1:500 diluted Flank PCR product as the
PCR templates: 95.degree. C. 5 Min 1 cycle 95.degree. C. 30 Sec
55.degree. C. 30 Sec 72.degree. C. 40 Sec 36 cycles 72.degree. C. 5
Min 1 cycle INSIDE PCR for APC, MGMT, DAPK, RASSF1A 95.degree. C. 5
Min 1 cycle 95.degree. C. 30 Sec 60.degree. C. 30 Sec 72.degree. C.
30 Sec 25 cycles 72.degree. C. 5 Min 1 cycle INSIDE FOR P16:
95.degree. C. 5 Min 1 cycle 95.degree. C. 30 Sec 64.degree. C. 30
Sec 72.degree. C. 30 Sec 20 cycles 72.degree. C. 5 Min 1 cycle
INSIDE FOR ASC: 95.degree. C. 5 Min 1 cycle 95.degree. C. 30 Sec
66.degree. C. 30 Sec 72.degree. C. 30 Sec 20 cycles 72.degree. C. 5
Min 1 cycle INSIDE for H-CADHERIN: 95.degree. C. 5 Min 1 cycle
95.degree. C. 30 Sec 64.degree. C. 30 Sec 72.degree. C. 30 Sec 30
cycles 72.degree. C. 5 Min 1 cycle
FIG. 3 shows methylation specific PCR for the H-cadherin gene in 36
samples of tumors and lymph nodes, numbered at top of each panel. *
represents the molecular weight marker. For each sample, the
presence of a visible PCR product in Lanes U indicates the presence
of an unmethylated promoter region amplified and serves as a
control for sample preparation; the presence of product in Lanes M
indicates a methylated gene promoter and was scored as positive for
methylation. Samples 7 and 16 did not amplify for this gene.
Samples 1, 2, 3, 4, 8, 9, 11, 13, 14, 20, 21, 22, 23, 26, 30, 32,
33, 36 are scored as unmethylated. Samples 5, 10, 12, 15, 17, 18,
19, 25, 27, 28, 31, 34, and 35 are methylated and samples 24 and 29
had very minimal M amplification that was scored as negative.
Placental DNA treated in vitro with SssI methyltransferase (New
England Biolabs, Beverly, Mass.) was used as a positive control.
DNA from normal lymphocytes and water (bisulfite-modified and
unmodified water) were used as negative controls. PCR products were
visualized using 2% agarose or 6% nondenaturing polyacrylamide
gels, and visually scored as methylated or unmethylated according
to the presence or absence of a PCR product (FIG. 3), blinded to
both the clinical outcomes and sources of DNA. (9, 25, 27).
Statistical Methods
Histopathological results and reports of events (death, or
recurrent disease) were verified during follow-up by reexamining
original hospital paper and electronic records. The primary
endpoint was recurrent disease (including local, regional, and
distant recurrences), measured from the date of surgery to
cancer-related death or censor. Control subjects who were alive and
had no evidence of disease at the end of study were censored for
recurrence and death. All deaths were cancer-related and no
subjects were lost to follow-up. The association between prognostic
factors and recurrence (case vs. control) was assessed using
univariable and multivariable logistic regression. Results of all
models are reported as relative risks with 95% confidence intervals
(Stata Statistical Software, College Station, Tex.). Associations
were considered to be significant when P was <0.05
(two-sided).
It was hypothesized that 40 percent or more of the cases would have
positive microscopic disease in their lymph nodes. For controls,
this number was expected to be less than or equal to 20 percent,
yielding a risk ratio of 2. Under these assumptions, the study
would have 80 percent power to detect the effect as statistically
significant (two-sided 0.05 alpha level test) with 167 subjects and
2:1 matching.
The present invention has been described in detail, including the
preferred embodiments thereof. However, it will be appreciated that
those skilled in the art, upon consideration of the present
disclosure, may make modifications and/or improvements of this
invention and still be within the scope and spirit of this
invention as set forth in the following claims.
All publications and patent documents cited in this application are
incorporated by reference in their entirety for all purposes to the
same extent as if each individual publication or patent document
were so individually denoted. By their citation of various
references in this document, Applicants do not admit any particular
reference is "prior art" to their invention.
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SEQUENCE LISTINGS
1
71713PRTHomo sapiens 1Met Gln Pro Arg Thr Pro Leu Val Leu Cys Val
Leu Leu Ser Gln Val1 5 10 15Leu Leu Leu Thr Ser Ala Glu Asp Leu Asp
Cys Thr Pro Gly Phe Gln 20 25 30Gln Lys Val Phe His Ile Asn Gln Pro
Ala Glu Phe Ile Glu Asp Gln 35 40 45Ser Ile Leu Asn Leu Thr Phe Ser
Asp Cys Lys Gly Asn Asp Lys Leu 50 55 60Arg Tyr Glu Val Ser Ser Pro
Tyr Phe Lys Val Asn Ser Asp Gly Gly65 70 75 80Leu Val Ala Leu Arg
Asn Ile Thr Ala Val Gly Lys Thr Leu Phe Val 85 90 95His Ala Arg Thr
Pro His Ala Glu Asp Met Ala Glu Leu Val Ile Val 100 105 110Gly Gly
Lys Asp Ile Gln Gly Ser Leu Gln Asp Ile Phe Lys Phe Ala 115 120
125Arg Thr Ser Pro Val Pro Arg Gln Lys Arg Ser Ile Val Val Ser Pro
130 135 140Ile Leu Ile Pro Glu Asn Gln Arg Gln Pro Phe Pro Arg Asp
Val Gly145 150 155 160Lys Val Val Asp Ser Asp Arg Pro Glu Arg Ser
Lys Phe Arg Leu Thr 165 170 175Gly Lys Gly Val Asp Gln Glu Pro Lys
Gly Ile Phe Arg Ile Asn Glu 180 185 190Asn Thr Gly Ser Val Ser Val
Thr Arg Thr Leu Asp Arg Glu Val Ile 195 200 205Ala Val Tyr Gln Leu
Phe Val Glu Thr Thr Asp Val Asn Gly Lys Thr 210 215 220Leu Glu Gly
Pro Val Pro Leu Glu Val Ile Val Ile Asp Gln Asn Asp225 230 235
240Asn Arg Pro Ile Phe Arg Glu Gly Pro Tyr Ile Gly His Val Met Glu
245 250 255Gly Ser Pro Thr Gly Thr Thr Val Met Arg Met Thr Ala Phe
Asp Ala 260 265 270Asp Asp Pro Ala Thr Asp Asn Ala Leu Leu Arg Tyr
Asn Ile Arg Gln 275 280 285Gln Thr Pro Asp Lys Pro Ser Pro Asn Met
Phe Tyr Ile Asp Pro Glu 290 295 300Lys Gly Asp Ile Val Thr Val Val
Ser Pro Ala Leu Leu Asp Arg Glu305 310 315 320Thr Leu Glu Asn Pro
Lys Tyr Glu Leu Ile Ile Glu Ala Gln Asp Met 325 330 335Ala Gly Leu
Asp Val Gly Leu Thr Gly Thr Ala Thr Ala Thr Ile Met 340 345 350Ile
Asp Asp Lys Asn Asp His Ser Pro Lys Phe Thr Lys Lys Glu Phe 355 360
365Gln Ala Thr Val Glu Glu Gly Ala Val Gly Val Ile Val Asn Leu Thr
370 375 380Val Glu Asp Lys Asp Asp Pro Thr Thr Gly Ala Trp Arg Ala
Ala Tyr385 390 395 400Thr Ile Ile Asn Gly Asn Pro Gly Gln Ser Phe
Glu Ile His Thr Asn 405 410 415Pro Gln Thr Asn Glu Gly Met Leu Ser
Val Val Lys Pro Leu Asp Tyr 420 425 430Glu Ile Ser Ala Phe His Thr
Leu Leu Ile Lys Val Glu Asn Glu Asp 435 440 445Pro Leu Val Pro Asp
Val Ser Tyr Gly Pro Ser Ser Thr Ala Thr Val 450 455 460His Ile Thr
Val Leu Asp Val Asn Glu Gly Pro Val Phe Tyr Pro Asp465 470 475
480Pro Met Met Val Thr Arg Gln Glu Asp Leu Ser Val Gly Ser Val Leu
485 490 495Leu Thr Val Asn Ala Thr Asp Pro Asp Ser Leu Gln His Gln
Thr Ile 500 505 510Arg Tyr Ser Val Tyr Lys Asp Pro Ala Gly Trp Leu
Asn Ile Asn Pro 515 520 525Ile Asn Gly Thr Val Asp Thr Thr Ala Val
Leu Asp Arg Glu Ser Pro 530 535 540Phe Val Asp Asn Ser Val Tyr Thr
Ala Leu Phe Leu Ala Ile Asp Ser545 550 555 560Gly Asn Pro Pro Ala
Thr Gly Thr Gly Thr Leu Leu Ile Thr Leu Glu 565 570 575Asp Val Asn
Asp Asn Ala Pro Phe Ile Tyr Pro Thr Val Ala Glu Val 580 585 590Cys
Asp Asp Ala Lys Asn Leu Ser Val Val Ile Leu Gly Ala Ser Asp 595 600
605Lys Asp Leu His Pro Asn Thr Asp Pro Phe Lys Phe Glu Ile His Lys
610 615 620Gln Ala Val Pro Asp Lys Val Trp Lys Ile Ser Lys Ile Asn
Asn Thr625 630 635 640His Ala Leu Val Ser Leu Leu Gln Asn Leu Asn
Lys Ala Asn Tyr Asn 645 650 655Leu Pro Ile Met Val Thr Asp Ser Gly
Lys Pro Pro Met Thr Asn Ile 660 665 670Thr Asp Leu Arg Val Gln Val
Cys Ser Cys Arg Asn Ser Lys Val Asp 675 680 685Cys Asn Ala Ala Gly
Ala Leu Arg Phe Ser Leu Pro Ser Val Leu Leu 690 695 700Leu Ser Leu
Phe Ser Leu Ala Cys Leu705 7102182PRTHomo sapiens 2Gly Ser His Ser
Met Arg Tyr Phe Phe Thr Ser Val Ser Arg Pro Gly1 5 10 15Arg Gly Glu
Pro Arg Phe Ile Ala Val Gly Tyr Val Asp Asp Thr Gln 20 25 30Phe Val
Arg Phe Asp Ser Asp Ala Ala Ser Gln Arg Met Glu Pro Arg 35 40 45Ala
Pro Trp Ile Glu Gln Glu Gly Pro Glu Tyr Trp Asp Gly Glu Thr 50 55
60Arg Lys Val Lys Ala His Ser Gln Thr Asp Arg Val Asp Leu Gly Thr65
70 75 80Leu Arg Gly Tyr Tyr Asn Gln Ser Glu Ala Gly Ser His Thr Ile
Gln 85 90 95Met Met Tyr Gly Cys Asp Val Gly Pro Asp Gly Arg Leu Leu
Arg Gly 100 105 110Tyr Gln Gln Asp Ala Tyr Asp Gly Lys Asp Tyr Ile
Ala Leu Asn Glu 115 120 125Asp Leu Arg Ser Trp Thr Ala Ala Asp Met
Ala Ala Gln Ile Thr Gln 130 135 140Arg Lys Trp Glu Ala Ala Arg Val
Ala Glu Gln Leu Arg Ala Tyr Leu145 150 155 160Glu Gly Thr Cys Val
Glu Trp Leu Arg Arg Tyr Leu Glu Asn Gly Lys 165 170 175Glu Thr Leu
Gln Arg Thr 18032843PRTHomo sapiens 3Met Ala Ala Ala Ser Tyr Asp
Gln Leu Leu Lys Gln Val Glu Ala Leu1 5 10 15Lys Met Glu Asn Ser Asn
Leu Arg Gln Glu Leu Glu Asp Asn Ser Asn 20 25 30His Leu Thr Lys Leu
Glu Thr Glu Ala Ser Asn Met Lys Glu Val Leu 35 40 45Lys Gln Leu Gln
Gly Ser Ile Glu Asp Glu Ala Met Ala Ser Ser Gly 50 55 60Gln Ile Asp
Leu Leu Glu Arg Leu Lys Glu Leu Asn Leu Asp Ser Ser65 70 75 80Asn
Phe Pro Gly Val Lys Leu Arg Ser Lys Met Ser Leu Arg Ser Tyr 85 90
95Gly Ser Arg Glu Gly Ser Val Ser Ser Arg Ser Gly Glu Cys Ser Pro
100 105 110Val Pro Met Gly Ser Phe Pro Arg Arg Gly Phe Val Asn Gly
Ser Arg 115 120 125Glu Ser Thr Gly Tyr Leu Glu Glu Leu Glu Lys Glu
Arg Ser Leu Leu 130 135 140Leu Ala Asp Leu Asp Lys Glu Glu Lys Glu
Lys Asp Trp Tyr Tyr Ala145 150 155 160Gln Leu Gln Asn Leu Thr Lys
Arg Ile Asp Ser Leu Pro Leu Thr Glu 165 170 175Asn Phe Ser Leu Gln
Thr Asp Met Thr Arg Arg Gln Leu Glu Tyr Glu 180 185 190Ala Arg Gln
Ile Arg Val Ala Met Glu Glu Gln Leu Gly Thr Cys Gln 195 200 205Asp
Met Glu Lys Arg Ala Gln Arg Arg Ile Ala Arg Ile Gln Gln Ile 210 215
220Glu Lys Asp Ile Leu Arg Ile Arg Gln Leu Leu Gln Ser Gln Ala
Thr225 230 235 240Glu Ala Glu Arg Ser Ser Gln Asn Lys His Glu Thr
Gly Ser His Asp 245 250 255Ala Glu Arg Gln Asn Glu Gly Gln Gly Val
Gly Glu Ile Asn Met Ala 260 265 270Thr Ser Gly Asn Gly Gln Gly Ser
Thr Thr Arg Met Asp His Glu Thr 275 280 285Ala Ser Val Leu Ser Ser
Ser Ser Thr His Ser Ala Pro Arg Arg Leu 290 295 300Thr Ser His Leu
Gly Thr Lys Val Glu Met Val Tyr Ser Leu Leu Ser305 310 315 320Met
Leu Gly Thr His Asp Lys Asp Asp Met Ser Arg Thr Leu Leu Ala 325 330
335Met Ser Ser Ser Gln Asp Ser Cys Ile Ser Met Arg Gln Ser Gly Cys
340 345 350Leu Pro Leu Leu Ile Gln Leu Leu His Gly Asn Asp Lys Asp
Ser Val 355 360 365Leu Leu Gly Asn Ser Arg Gly Ser Lys Glu Ala Arg
Ala Arg Ala Ser 370 375 380Ala Ala Leu His Asn Ile Ile His Ser Gln
Pro Asp Asp Lys Arg Gly385 390 395 400Arg Arg Glu Ile Arg Val Leu
His Leu Leu Glu Gln Ile Arg Ala Tyr 405 410 415Cys Glu Thr Cys Trp
Glu Trp Gln Glu Ala His Glu Pro Gly Met Asp 420 425 430Gln Asp Lys
Asn Pro Met Pro Ala Pro Val Glu His Gln Ile Cys Pro 435 440 445Ala
Val Cys Val Leu Met Lys Leu Ser Phe Asp Glu Glu His Arg His 450 455
460Ala Met Asn Glu Leu Gly Gly Leu Gln Ala Ile Ala Glu Leu Leu
Gln465 470 475 480Val Asp Cys Glu Met Tyr Gly Leu Thr Asn Asp His
Tyr Ser Ile Thr 485 490 495Leu Arg Arg Tyr Ala Gly Met Ala Leu Thr
Asn Leu Thr Phe Gly Asp 500 505 510Val Ala Asn Lys Ala Thr Leu Cys
Ser Met Lys Gly Cys Met Arg Ala 515 520 525Leu Val Ala Gln Leu Lys
Ser Glu Ser Glu Asp Leu Gln Gln Val Ile 530 535 540Ala Ser Val Leu
Arg Asn Leu Ser Trp Arg Ala Asp Val Asn Ser Lys545 550 555 560Lys
Thr Leu Arg Glu Val Gly Ser Val Lys Ala Leu Met Glu Cys Ala 565 570
575Leu Glu Val Lys Lys Glu Ser Thr Leu Lys Ser Val Leu Ser Ala Leu
580 585 590Trp Asn Leu Ser Ala His Cys Thr Glu Asn Lys Ala Asp Ile
Cys Ala 595 600 605Val Asp Gly Ala Leu Ala Phe Leu Val Gly Thr Leu
Thr Tyr Arg Ser 610 615 620Gln Thr Asn Thr Leu Ala Ile Ile Glu Ser
Gly Gly Gly Ile Leu Arg625 630 635 640Asn Val Ser Ser Leu Ile Ala
Thr Asn Glu Asp His Arg Gln Ile Leu 645 650 655Arg Glu Asn Asn Cys
Leu Gln Thr Leu Leu Gln His Leu Lys Ser His 660 665 670Ser Leu Thr
Ile Val Ser Asn Ala Cys Gly Thr Leu Trp Asn Leu Ser 675 680 685Ala
Arg Asn Pro Lys Asp Gln Glu Ala Leu Trp Asp Met Gly Ala Val 690 695
700Ser Met Leu Lys Asn Leu Ile His Ser Lys His Lys Met Ile Ala
Met705 710 715 720Gly Ser Ala Ala Ala Leu Arg Asn Leu Met Ala Asn
Arg Pro Ala Lys 725 730 735Tyr Lys Asp Ala Asn Ile Met Ser Pro Gly
Ser Ser Leu Pro Ser Leu 740 745 750His Val Arg Lys Gln Lys Ala Leu
Glu Ala Glu Leu Asp Ala Gln His 755 760 765Leu Ser Glu Thr Phe Asp
Asn Ile Asp Asn Leu Ser Pro Lys Ala Ser 770 775 780His Arg Ser Lys
Gln Arg His Lys Gln Ser Leu Tyr Gly Asp Tyr Val785 790 795 800Phe
Asp Thr Asn Arg His Asp Asp Asn Arg Ser Asp Asn Phe Asn Thr 805 810
815Gly Asn Met Thr Val Leu Ser Pro Tyr Leu Asn Thr Thr Val Leu Pro
820 825 830Ser Ser Ser Ser Ser Arg Gly Ser Leu Asp Ser Ser Arg Ser
Glu Lys 835 840 845Asp Arg Ser Leu Glu Arg Glu Arg Gly Ile Gly Leu
Gly Asn Tyr His 850 855 860Pro Ala Thr Glu Asn Pro Gly Thr Ser Ser
Lys Arg Gly Leu Gln Ile865 870 875 880Ser Thr Thr Ala Ala Gln Ile
Ala Lys Val Met Glu Glu Val Ser Ala 885 890 895Ile His Thr Ser Gln
Glu Asp Arg Ser Ser Gly Ser Thr Thr Glu Leu 900 905 910His Cys Val
Thr Asp Glu Arg Asn Ala Leu Arg Arg Ser Ser Ala Ala 915 920 925His
Thr His Ser Asn Thr Tyr Asn Phe Thr Lys Ser Glu Asn Ser Asn 930 935
940Arg Thr Cys Ser Met Pro Tyr Ala Lys Leu Glu Tyr Lys Arg Ser
Ser945 950 955 960Asn Asp Ser Leu Asn Ser Val Ser Ser Ser Asp Gly
Tyr Gly Lys Arg 965 970 975Gly Gln Met Lys Pro Ser Ile Glu Ser Tyr
Ser Glu Asp Asp Glu Ser 980 985 990Lys Phe Cys Ser Tyr Gly Gln Tyr
Pro Ala Asp Leu Ala His Lys Ile 995 1000 1005His Ser Ala Asn His
Met Asp Asp Asn Asp Gly Glu Leu Asp Thr 1010 1015 1020Pro Ile Asn
Tyr Ser Leu Lys Tyr Ser Asp Glu Gln Leu Asn Ser 1025 1030 1035Gly
Arg Gln Ser Pro Ser Gln Asn Glu Arg Trp Ala Arg Pro Lys 1040 1045
1050His Ile Ile Glu Asp Glu Ile Lys Gln Ser Glu Gln Arg Gln Ser
1055 1060 1065Arg Asn Gln Ser Thr Thr Tyr Pro Val Tyr Thr Glu Ser
Thr Asp 1070 1075 1080Asp Lys His Leu Lys Phe Gln Pro His Phe Gly
Gln Gln Glu Cys 1085 1090 1095Val Ser Pro Tyr Arg Ser Arg Gly Ala
Asn Gly Ser Glu Thr Asn 1100 1105 1110Arg Val Gly Ser Asn His Gly
Ile Asn Gln Asn Val Ser Gln Ser 1115 1120 1125Leu Cys Gln Glu Asp
Asp Tyr Glu Asp Asp Lys Pro Thr Asn Tyr 1130 1135 1140Ser Glu Arg
Tyr Ser Glu Glu Glu Gln His Glu Glu Glu Glu Arg 1145 1150 1155Pro
Thr Asn Tyr Ser Ile Lys Tyr Asn Glu Glu Lys Arg His Val 1160 1165
1170Asp Gln Pro Ile Asp Tyr Ser Leu Lys Tyr Ala Thr Asp Ile Pro
1175 1180 1185Ser Ser Gln Lys Gln Ser Phe Ser Phe Ser Lys Ser Ser
Ser Gly 1190 1195 1200Gln Ser Ser Lys Thr Glu His Met Ser Ser Ser
Ser Glu Asn Thr 1205 1210 1215Ser Thr Pro Ser Ser Asn Ala Lys Arg
Gln Asn Gln Leu His Pro 1220 1225 1230Ser Ser Ala Gln Ser Arg Ser
Gly Gln Pro Gln Lys Ala Ala Thr 1235 1240 1245Cys Lys Val Ser Ser
Ile Asn Gln Glu Thr Ile Gln Thr Tyr Cys 1250 1255 1260Val Glu Asp
Thr Pro Ile Cys Phe Ser Arg Cys Ser Ser Leu Ser 1265 1270 1275Ser
Leu Ser Ser Ala Glu Asp Glu Ile Gly Cys Asn Gln Thr Thr 1280 1285
1290Gln Glu Ala Asp Ser Ala Asn Thr Leu Gln Ile Ala Glu Ile Lys
1295 1300 1305Glu Lys Ile Gly Thr Arg Ser Ala Glu Asp Pro Val Ser
Glu Val 1310 1315 1320Pro Ala Val Ser Gln His Pro Arg Thr Lys Ser
Ser Arg Leu Gln 1325 1330 1335Gly Ser Ser Leu Ser Ser Glu Ser Ala
Arg His Lys Ala Val Glu 1340 1345 1350Phe Ser Ser Gly Ala Lys Ser
Pro Ser Lys Ser Gly Ala Gln Thr 1355 1360 1365Pro Lys Ser Pro Pro
Glu His Tyr Val Gln Glu Thr Pro Leu Met 1370 1375 1380Phe Ser Arg
Cys Thr Ser Val Ser Ser Leu Asp Ser Phe Glu Ser 1385 1390 1395Arg
Ser Ile Ala Ser Ser Val Gln Ser Glu Pro Cys Ser Gly Met 1400 1405
1410Val Ser Gly Ile Ile Ser Pro Ser Asp Leu Pro Asp Ser Pro Gly
1415 1420 1425Gln Thr Met Pro Pro Ser Arg Ser Lys Thr Pro Pro Pro
Pro Pro 1430 1435 1440Gln Thr Ala Gln Thr Lys Arg Glu Val Pro Lys
Asn Lys Ala Pro 1445 1450 1455Thr Ala Glu Lys Arg Glu Ser Gly Pro
Lys Gln Ala Ala Val Asn 1460 1465 1470Ala Ala Val Gln Arg Val Gln
Val Leu Pro Asp Ala Asp Thr Leu 1475 1480 1485Leu His Phe Ala Thr
Glu Ser Thr Pro Asp Gly Phe Ser Cys Ser 1490 1495 1500Ser Ser Leu
Ser Ala Leu Ser Leu Asp Glu Pro Phe Ile Gln Lys 1505 1510 1515Asp
Val Glu Leu Arg Ile Met Pro Pro Val Gln Glu Asn Asp Asn 1520 1525
1530Gly Asn Glu Thr Glu Ser Glu Gln Pro Lys Glu Ser Asn Glu Asn
1535 1540 1545Gln Glu Lys Glu Ala Glu Lys Thr Ile Asp Ser Glu Lys
Asp Leu 1550 1555 1560Leu Asp Asp Ser Asp
Asp Asp Asp Ile Glu Ile Leu Glu Glu Cys 1565 1570 1575Ile Ile Ser
Ala Met Pro Thr Lys Ser Ser Arg Lys Ala Lys Lys 1580 1585 1590Pro
Ala Gln Thr Ala Ser Lys Leu Pro Pro Pro Val Ala Arg Lys 1595 1600
1605Pro Ser Gln Leu Pro Val Tyr Lys Leu Leu Pro Ser Gln Asn Arg
1610 1615 1620Leu Gln Pro Gln Lys His Val Ser Phe Thr Pro Gly Asp
Asp Met 1625 1630 1635Pro Arg Val Tyr Cys Val Glu Gly Thr Pro Ile
Asn Phe Ser Thr 1640 1645 1650Ala Thr Ser Leu Ser Asp Leu Thr Ile
Glu Ser Pro Pro Asn Glu 1655 1660 1665Leu Ala Ala Gly Glu Gly Val
Arg Gly Gly Ala Gln Ser Gly Glu 1670 1675 1680Phe Glu Lys Arg Asp
Thr Ile Pro Thr Glu Gly Arg Ser Thr Asp 1685 1690 1695Glu Ala Gln
Gly Gly Lys Thr Ser Ser Val Thr Ile Pro Glu Leu 1700 1705 1710Asp
Asp Asn Lys Ala Glu Glu Gly Asp Ile Leu Ala Glu Cys Ile 1715 1720
1725Asn Ser Ala Met Pro Lys Gly Lys Ser His Lys Pro Phe Arg Val
1730 1735 1740Lys Lys Ile Met Asp Gln Val Gln Gln Ala Ser Ala Ser
Ser Ser 1745 1750 1755Ala Pro Asn Lys Asn Gln Leu Asp Gly Lys Lys
Lys Lys Pro Thr 1760 1765 1770Ser Pro Val Lys Pro Ile Pro Gln Asn
Thr Glu Tyr Arg Thr Arg 1775 1780 1785Val Arg Lys Asn Ala Asp Ser
Lys Asn Asn Leu Asn Ala Glu Arg 1790 1795 1800Val Phe Ser Asp Asn
Lys Asp Ser Lys Lys Gln Asn Leu Lys Asn 1805 1810 1815Asn Ser Lys
Val Phe Asn Asp Lys Leu Pro Asn Asn Glu Asp Arg 1820 1825 1830Val
Arg Gly Ser Phe Ala Phe Asp Ser Pro His His Tyr Thr Pro 1835 1840
1845Ile Glu Gly Thr Pro Tyr Cys Phe Ser Arg Asn Asp Ser Leu Ser
1850 1855 1860Ser Leu Asp Phe Asp Asp Asp Asp Val Asp Leu Ser Arg
Glu Lys 1865 1870 1875Ala Glu Leu Arg Lys Ala Lys Glu Asn Lys Glu
Ser Glu Ala Lys 1880 1885 1890Val Thr Ser His Thr Glu Leu Thr Ser
Asn Gln Gln Ser Ala Asn 1895 1900 1905Lys Thr Gln Ala Ile Ala Lys
Gln Pro Ile Asn Arg Gly Gln Pro 1910 1915 1920Lys Pro Ile Leu Gln
Lys Gln Ser Thr Phe Pro Gln Ser Ser Lys 1925 1930 1935Asp Ile Pro
Asp Arg Gly Ala Ala Thr Asp Glu Lys Leu Gln Asn 1940 1945 1950Phe
Ala Ile Glu Asn Thr Pro Val Cys Phe Ser His Asn Ser Ser 1955 1960
1965Leu Ser Ser Leu Ser Asp Ile Asp Gln Glu Asn Asn Asn Lys Glu
1970 1975 1980Asn Glu Pro Ile Lys Glu Thr Glu Pro Pro Asp Ser Gln
Gly Glu 1985 1990 1995Pro Ser Lys Pro Gln Ala Ser Gly Tyr Ala Pro
Lys Ser Phe His 2000 2005 2010Val Glu Asp Thr Pro Val Cys Phe Ser
Arg Asn Ser Ser Leu Ser 2015 2020 2025Ser Leu Ser Ile Asp Ser Glu
Asp Asp Leu Leu Gln Glu Cys Ile 2030 2035 2040Ser Ser Ala Met Pro
Lys Lys Lys Lys Pro Ser Arg Leu Lys Gly 2045 2050 2055Asp Asn Glu
Lys His Ser Pro Arg Asn Met Gly Gly Ile Leu Gly 2060 2065 2070Glu
Asp Leu Thr Leu Asp Leu Lys Asp Ile Gln Arg Pro Asp Ser 2075 2080
2085Glu His Gly Leu Ser Pro Asp Ser Glu Asn Phe Asp Trp Lys Ala
2090 2095 2100Ile Gln Glu Gly Ala Asn Ser Ile Val Ser Ser Leu His
Gln Ala 2105 2110 2115Ala Ala Ala Ala Cys Leu Ser Arg Gln Ala Ser
Ser Asp Ser Asp 2120 2125 2130Ser Ile Leu Ser Leu Lys Ser Gly Ile
Ser Leu Gly Ser Pro Phe 2135 2140 2145His Leu Thr Pro Asp Gln Glu
Glu Lys Pro Phe Thr Ser Asn Lys 2150 2155 2160Gly Pro Arg Ile Leu
Lys Pro Gly Glu Lys Ser Thr Leu Glu Thr 2165 2170 2175Lys Lys Ile
Glu Ser Glu Ser Lys Gly Ile Lys Gly Gly Lys Lys 2180 2185 2190Val
Tyr Lys Ser Leu Ile Thr Gly Lys Val Arg Ser Asn Ser Glu 2195 2200
2205Ile Ser Gly Gln Met Lys Gln Pro Leu Gln Ala Asn Met Pro Ser
2210 2215 2220Ile Ser Arg Gly Arg Thr Met Ile His Ile Pro Gly Val
Arg Asn 2225 2230 2235Ser Ser Ser Ser Thr Ser Pro Val Ser Lys Lys
Gly Pro Pro Leu 2240 2245 2250Lys Thr Pro Ala Ser Lys Ser Pro Ser
Glu Gly Gln Thr Ala Thr 2255 2260 2265Thr Ser Pro Arg Gly Ala Lys
Pro Ser Val Lys Ser Glu Leu Ser 2270 2275 2280Pro Val Ala Arg Gln
Thr Ser Gln Ile Gly Gly Ser Ser Lys Ala 2285 2290 2295Pro Ser Arg
Ser Gly Ser Arg Asp Ser Thr Pro Ser Arg Pro Ala 2300 2305 2310Gln
Gln Pro Leu Ser Arg Pro Ile Gln Ser Pro Gly Arg Asn Ser 2315 2320
2325Ile Ser Pro Gly Arg Asn Gly Ile Ser Pro Pro Asn Lys Leu Ser
2330 2335 2340Gln Leu Pro Arg Thr Ser Ser Pro Ser Thr Ala Ser Thr
Lys Ser 2345 2350 2355Ser Gly Ser Gly Lys Met Ser Tyr Thr Ser Pro
Gly Arg Gln Met 2360 2365 2370Ser Gln Gln Asn Leu Thr Lys Gln Thr
Gly Leu Ser Lys Asn Ala 2375 2380 2385Ser Ser Ile Pro Arg Ser Glu
Ser Ala Ser Lys Gly Leu Asn Gln 2390 2395 2400Met Asn Asn Gly Asn
Gly Ala Asn Lys Lys Val Glu Leu Ser Arg 2405 2410 2415Met Ser Ser
Thr Lys Ser Ser Gly Ser Glu Ser Asp Arg Ser Glu 2420 2425 2430Arg
Pro Val Leu Val Arg Gln Ser Thr Phe Ile Lys Glu Ala Pro 2435 2440
2445Ser Pro Thr Leu Arg Arg Lys Leu Glu Glu Ser Ala Ser Phe Glu
2450 2455 2460Ser Leu Ser Pro Ser Ser Arg Pro Ala Ser Pro Thr Arg
Ser Gln 2465 2470 2475Ala Gln Thr Pro Val Leu Ser Pro Ser Leu Pro
Asp Met Ser Leu 2480 2485 2490Ser Thr His Ser Ser Val Gln Ala Gly
Gly Trp Arg Lys Leu Pro 2495 2500 2505Pro Asn Leu Ser Pro Thr Ile
Glu Tyr Asn Asp Gly Arg Pro Ala 2510 2515 2520Lys Arg His Asp Ile
Ala Arg Ser His Ser Glu Ser Pro Ser Arg 2525 2530 2535Leu Pro Ile
Asn Arg Ser Gly Thr Trp Lys Arg Glu His Ser Lys 2540 2545 2550His
Ser Ser Ser Leu Pro Arg Val Ser Thr Trp Arg Arg Thr Gly 2555 2560
2565Ser Ser Ser Ser Ile Leu Ser Ala Ser Ser Glu Ser Ser Glu Lys
2570 2575 2580Ala Lys Ser Glu Asp Glu Lys His Val Asn Ser Ile Ser
Gly Thr 2585 2590 2595Lys Gln Ser Lys Glu Asn Gln Val Ser Ala Lys
Gly Thr Trp Arg 2600 2605 2610Lys Ile Lys Glu Asn Glu Phe Ser Pro
Thr Asn Ser Thr Ser Gln 2615 2620 2625Thr Val Ser Ser Gly Ala Thr
Asn Gly Ala Glu Ser Lys Thr Leu 2630 2635 2640Ile Tyr Gln Met Ala
Pro Ala Val Ser Lys Thr Glu Asp Val Trp 2645 2650 2655Val Arg Ile
Glu Asp Cys Pro Ile Asn Asn Pro Arg Ser Gly Arg 2660 2665 2670Ser
Pro Thr Gly Asn Thr Pro Pro Val Ile Asp Ser Val Ser Glu 2675 2680
2685Lys Ala Asn Pro Asn Ile Lys Asp Ser Lys Asp Asn Gln Ala Lys
2690 2695 2700Gln Asn Val Gly Asn Gly Ser Val Pro Met Arg Thr Val
Gly Leu 2705 2710 2715Glu Asn Arg Leu Asn Ser Phe Ile Gln Val Asp
Ala Pro Asp Gln 2720 2725 2730Lys Gly Thr Glu Ile Lys Pro Gly Gln
Asn Asn Pro Val Pro Val 2735 2740 2745Ser Glu Thr Asn Glu Ser Ser
Ile Val Glu Arg Thr Pro Phe Ser 2750 2755 2760Ser Ser Ser Ser Ser
Lys His Ser Ser Pro Ser Gly Thr Val Ala 2765 2770 2775Ala Arg Val
Thr Pro Phe Asn Tyr Asn Pro Ser Pro Arg Lys Ser 2780 2785 2790Ser
Ala Asp Ser Thr Ser Ala Arg Pro Ser Gln Ile Pro Thr Pro 2795 2800
2805Val Asn Asn Asn Thr Lys Lys Arg Asp Ser Lys Thr Asp Ser Thr
2810 2815 2820Glu Ser Ser Gly Thr Gln Ser Pro Lys Arg His Ser Gly
Ser Tyr 2825 2830 2835Leu Val Thr Ser Val 28404340PRTHomo sapiens
4Met Ser Gly Glu Pro Glu Leu Ile Glu Leu Arg Glu Leu Ala Pro Ala1 5
10 15Gly Arg Ala Gly Lys Gly Arg Thr Arg Leu Glu Arg Ala Asn Ala
Leu 20 25 30Arg Ile Ala Arg Gly Thr Ala Cys Asn Pro Thr Arg Gln Leu
Val Pro 35 40 45Gly Arg Gly His Arg Phe Gln Pro Ala Gly Pro Ala Thr
His Thr Trp 50 55 60Cys Asp Leu Cys Gly Asp Phe Ile Trp Gly Val Val
Arg Lys Gly Leu65 70 75 80Gln Cys Ala His Cys Lys Phe Thr Cys His
Tyr Arg Cys Arg Ala Leu 85 90 95Val Cys Leu Asp Cys Cys Gly Pro Arg
Asp Leu Gly Trp Glu Pro Ala 100 105 110Val Glu Arg Asp Thr Asn Val
Asp Glu Pro Val Glu Trp Glu Thr Pro 115 120 125Asp Leu Ser Gln Ala
Glu Ile Glu Gln Lys Ile Lys Glu Tyr Asn Ala 130 135 140Gln Ile Asn
Ser Asn Leu Phe Met Ser Leu Asn Lys Asp Gly Ser Tyr145 150 155
160Thr Gly Phe Ile Lys Val Gln Leu Lys Leu Val Arg Pro Val Ser Val
165 170 175Pro Ser Ser Lys Lys Pro Pro Ser Leu Gln Asp Ala Arg Arg
Gly Pro 180 185 190Gly Arg Gly Thr Ser Val Arg Arg Arg Thr Ser Phe
Tyr Leu Pro Lys 195 200 205Asp Ala Val Lys His Leu His Val Leu Ser
Arg Thr Arg Ala Arg Glu 210 215 220Val Ile Glu Ala Leu Leu Arg Lys
Phe Leu Val Val Asp Asp Pro Arg225 230 235 240Lys Phe Ala Leu Phe
Glu Arg Ala Glu Arg His Gly Gln Val Tyr Leu 245 250 255Arg Lys Leu
Leu Asp Asp Glu Gln Pro Leu Arg Leu Arg Leu Leu Ala 260 265 270Gly
Pro Ser Asp Lys Ala Leu Ser Phe Val Leu Lys Glu Asn Asp Ser 275 280
285Gly Glu Val Asn Trp Asp Ala Phe Ser Met Pro Glu Leu His Asn Phe
290 295 300Leu Arg Ile Leu Gln Arg Glu Glu Glu Glu His Leu Arg Gln
Ile Leu305 310 315 320Gln Lys Tyr Ser Tyr Cys Arg Gln Lys Ile Gln
Glu Ala Leu His Ala 325 330 335Cys Pro Leu Gly 3405207PRTHomo
sapiens 5Met Asp Lys Asp Cys Glu Met Lys Arg Thr Thr Leu Asp Ser
Pro Leu1 5 10 15Gly Lys Leu Glu Leu Ser Gly Cys Glu Gln Gly Leu His
Glu Ile Lys 20 25 30Leu Leu Gly Lys Gly Thr Ser Ala Ala Asp Ala Val
Glu Val Pro Ala 35 40 45Pro Ala Ala Val Leu Gly Gly Pro Glu Pro Leu
Met Gln Cys Thr Ala 50 55 60Trp Leu Asn Ala Tyr Phe His Gln Pro Glu
Ala Ile Glu Glu Phe Pro65 70 75 80Val Pro Ala Leu His His Pro Val
Phe Gln Gln Glu Ser Phe Thr Arg 85 90 95Gln Val Leu Trp Lys Leu Leu
Lys Val Val Lys Phe Gly Glu Val Ile 100 105 110Ser Tyr Gln Gln Leu
Ala Ala Leu Ala Gly Asn Pro Lys Ala Ala Arg 115 120 125Ala Val Gly
Gly Ala Met Arg Gly Asn Pro Val Pro Ile Leu Ile Pro 130 135 140Cys
His Arg Val Val Cys Ser Ser Gly Ala Val Gly Asn Tyr Ser Gly145 150
155 160Gly Leu Ala Val Lys Glu Trp Leu Leu Ala His Glu Gly His Arg
Leu 165 170 175Gly Lys Pro Gly Leu Gly Gly Ser Ser Gly Leu Ala Gly
Ala Trp Leu 180 185 190Lys Gly Ala Gly Ala Thr Ser Gly Ser Pro Pro
Ala Gly Arg Asn 195 200 20561430PRTHomo sapiens 6Met Thr Val Phe
Arg Gln Glu Asn Val Asp Asp Tyr Tyr Asp Thr Gly1 5 10 15Glu Glu Leu
Gly Ser Gly Gln Phe Ala Val Val Lys Lys Cys Arg Glu 20 25 30Lys Ser
Thr Gly Leu Gln Tyr Ala Ala Lys Phe Ile Lys Lys Arg Arg 35 40 45Thr
Lys Ser Ser Arg Arg Gly Val Ser Arg Glu Asp Ile Glu Arg Glu 50 55
60Val Ser Ile Leu Lys Glu Ile Gln His Pro Asn Val Ile Thr Leu His65
70 75 80Glu Val Tyr Glu Asn Lys Thr Asp Val Ile Leu Ile Leu Glu Leu
Val 85 90 95Ala Gly Gly Glu Leu Phe Asp Phe Leu Ala Glu Lys Glu Ser
Leu Thr 100 105 110Glu Glu Glu Ala Thr Glu Phe Leu Lys Gln Ile Leu
Asn Gly Val Tyr 115 120 125Tyr Leu His Ser Leu Gln Ile Ala His Phe
Asp Leu Lys Pro Glu Asn 130 135 140Ile Met Leu Leu Asp Arg Asn Val
Pro Lys Pro Arg Ile Lys Ile Ile145 150 155 160Asp Phe Gly Leu Ala
His Lys Ile Asp Phe Gly Asn Glu Phe Lys Asn 165 170 175Ile Phe Gly
Thr Pro Glu Phe Val Ala Pro Glu Ile Val Asn Tyr Glu 180 185 190Pro
Leu Gly Leu Glu Ala Asp Met Trp Ser Ile Gly Val Ile Thr Tyr 195 200
205Ile Leu Leu Ser Gly Ala Ser Pro Phe Leu Gly Asp Thr Lys Gln Glu
210 215 220Thr Leu Ala Asn Val Ser Ala Val Asn Tyr Glu Phe Glu Asp
Glu Tyr225 230 235 240Phe Ser Asn Thr Ser Ala Leu Ala Lys Asp Phe
Ile Arg Arg Leu Leu 245 250 255Val Lys Asp Pro Lys Lys Arg Met Thr
Ile Gln Asp Ser Leu Gln His 260 265 270Pro Trp Ile Lys Pro Lys Asp
Thr Gln Gln Ala Leu Ser Arg Lys Ala 275 280 285Ser Ala Val Asn Met
Glu Lys Phe Lys Lys Phe Ala Ala Arg Lys Lys 290 295 300Trp Lys Gln
Ser Val Arg Leu Ile Ser Leu Cys Gln Arg Leu Ser Arg305 310 315
320Ser Phe Leu Ser Arg Ser Asn Met Ser Val Ala Arg Ser Asp Asp Thr
325 330 335Leu Asp Glu Glu Asp Ser Phe Val Met Lys Ala Ile Ile His
Ala Ile 340 345 350Asn Asp Asp Asn Val Pro Gly Leu Gln His Leu Leu
Gly Ser Leu Ser 355 360 365Asn Tyr Asp Val Asn Gln Pro Asn Lys His
Gly Thr Pro Pro Leu Leu 370 375 380Ile Ala Ala Gly Cys Gly Asn Ile
Gln Ile Leu Gln Leu Leu Ile Lys385 390 395 400Arg Gly Ser Arg Ile
Asp Val Gln Asp Lys Gly Gly Ser Asn Ala Val 405 410 415Tyr Trp Ala
Ala Arg His Gly His Val Asp Thr Leu Lys Phe Leu Ser 420 425 430Glu
Asn Lys Cys Pro Leu Asp Val Lys Asp Lys Ser Gly Glu Met Ala 435 440
445Leu His Val Ala Ala Arg Tyr Gly His Ala Asp Val Ala Gln Leu Leu
450 455 460Cys Ser Phe Gly Ser Asn Pro Asn Ile Gln Asp Lys Glu Glu
Glu Thr465 470 475 480Pro Leu His Cys Ala Ala Trp His Gly Tyr Tyr
Ser Val Ala Lys Ala 485 490 495Leu Cys Glu Ala Gly Cys Asn Val Asn
Ile Lys Asn Arg Glu Gly Glu 500 505 510Thr Pro Leu Leu Thr Ala Ser
Ala Arg Gly Tyr His Asp Ile Val Glu 515 520 525Cys Leu Ala Glu His
Gly Ala Asp Leu Asn Ala Cys Asp Lys Asp Gly 530 535 540His Ile Ala
Leu His Leu Ala Val Arg Arg Cys Gln Met Glu Val Ile545 550 555
560Lys Thr Leu Leu Ser Gln Gly Cys Phe Val Asp Tyr Gln Asp Arg His
565 570 575Gly Asn Thr Pro Leu His Val Ala Cys Lys Asp Gly Asn Met
Pro Ile 580 585 590Val Val Ala Leu Cys Glu Ala Asn Cys Asn Leu Asp
Ile Ser Asn Lys 595 600 605Tyr Gly Arg Thr Pro Leu His Leu Ala Ala
Asn Asn Gly Ile Leu Asp 610 615 620Val Val Arg
Tyr Leu Cys Leu Met Gly Ala Ser Val Glu Ala Leu Thr625 630 635
640Thr Asp Gly Lys Thr Ala Glu Asp Leu Ala Arg Ser Glu Gln His Glu
645 650 655His Val Ala Gly Leu Leu Ala Arg Leu Arg Lys Asp Thr His
Arg Gly 660 665 670Leu Phe Ile Gln Gln Leu Arg Pro Thr Gln Asn Leu
Gln Pro Arg Ile 675 680 685Lys Leu Lys Leu Phe Gly His Ser Gly Ser
Gly Lys Thr Thr Leu Val 690 695 700Glu Ser Leu Lys Cys Gly Leu Leu
Arg Ser Phe Phe Arg Arg Arg Arg705 710 715 720Pro Arg Leu Ser Ser
Thr Asn Ser Ser Arg Phe Pro Pro Ser Pro Leu 725 730 735Ala Ser Lys
Pro Thr Val Ser Val Ser Ile Asn Asn Leu Tyr Pro Gly 740 745 750Cys
Glu Asn Val Ser Val Arg Ser Arg Ser Met Met Phe Glu Pro Gly 755 760
765Leu Thr Lys Gly Met Leu Glu Val Phe Val Ala Pro Thr His His Pro
770 775 780His Cys Ser Ala Asp Asp Gln Ser Thr Lys Ala Ile Asp Ile
Gln Asn785 790 795 800Ala Tyr Leu Asn Gly Val Gly Asp Phe Ser Val
Trp Glu Phe Ser Gly 805 810 815Asn Pro Val Tyr Phe Cys Cys Tyr Asp
Tyr Phe Ala Ala Asn Asp Pro 820 825 830Thr Ser Ile His Val Val Val
Phe Ser Leu Glu Glu Pro Tyr Glu Ile 835 840 845Gln Leu Asn Gln Val
Ile Phe Trp Leu Ser Phe Leu Lys Ser Leu Val 850 855 860Pro Val Glu
Glu Pro Ile Ala Phe Gly Gly Lys Leu Lys Asn Pro Leu865 870 875
880Gln Val Val Leu Val Ala Thr His Ala Asp Ile Met Asn Val Pro Arg
885 890 895Pro Ala Gly Gly Glu Phe Gly Tyr Asp Lys Asp Thr Ser Leu
Leu Lys 900 905 910Glu Ile Arg Asn Arg Phe Gly Asn Asp Leu His Ile
Ser Asn Lys Leu 915 920 925Phe Val Leu Asp Ala Gly Ala Ser Gly Ser
Lys Asp Met Lys Val Leu 930 935 940Arg Asn His Leu Gln Glu Ile Arg
Ser Gln Ile Val Ser Val Cys Pro945 950 955 960Pro Met Thr His Leu
Cys Glu Lys Ile Ile Ser Thr Leu Pro Ser Trp 965 970 975Arg Lys Leu
Asn Gly Pro Asn Gln Leu Met Ser Leu Gln Gln Phe Val 980 985 990Tyr
Asp Val Gln Asp Gln Leu Asn Pro Leu Ala Ser Glu Glu Asp Leu 995
1000 1005Arg Arg Ile Ala Gln Gln Leu His Ser Thr Gly Glu Ile Asn
Ile 1010 1015 1020Met Gln Ser Glu Thr Val Gln Asp Val Leu Leu Leu
Asp Pro Arg 1025 1030 1035Trp Leu Cys Thr Asn Val Leu Gly Lys Leu
Leu Ser Val Glu Thr 1040 1045 1050Pro Arg Ala Leu His His Tyr Arg
Gly Arg Tyr Thr Val Glu Asp 1055 1060 1065Ile Gln Arg Leu Val Pro
Asp Ser Asp Val Glu Glu Leu Leu Gln 1070 1075 1080Ile Leu Asp Ala
Met Asp Ile Cys Ala Arg Asp Leu Ser Ser Gly 1085 1090 1095Thr Met
Val Asp Val Pro Ala Leu Ile Lys Thr Asp Asn Leu His 1100 1105
1110Arg Ser Trp Ala Asp Glu Glu Asp Glu Val Met Val Tyr Gly Gly
1115 1120 1125Val Arg Ile Val Pro Val Glu His Leu Thr Pro Phe Pro
Cys Gly 1130 1135 1140Ile Phe His Lys Val Gln Val Asn Leu Cys Arg
Trp Ile His Gln 1145 1150 1155Gln Ser Thr Glu Gly Asp Ala Asp Ile
Arg Leu Trp Val Asn Gly 1160 1165 1170Cys Lys Leu Ala Asn Arg Gly
Ala Glu Leu Leu Val Leu Leu Val 1175 1180 1185Asn His Gly Gln Gly
Ile Glu Val Gln Val Arg Gly Leu Glu Thr 1190 1195 1200Glu Lys Ile
Lys Cys Cys Leu Leu Leu Asp Ser Val Cys Ser Thr 1205 1210 1215Ile
Glu Asn Val Met Ala Thr Thr Leu Pro Gly Leu Leu Thr Val 1220 1225
1230Lys His Tyr Leu Ser Pro Gln Gln Leu Arg Glu His His Glu Pro
1235 1240 1245Val Met Ile Tyr Gln Pro Arg Asp Phe Phe Arg Ala Gln
Thr Leu 1250 1255 1260Lys Glu Thr Ser Leu Thr Asn Thr Met Gly Gly
Tyr Lys Glu Ser 1265 1270 1275Phe Ser Ser Ile Met Cys Phe Gly Cys
His Asp Val Tyr Ser Gln 1280 1285 1290Ala Ser Leu Gly Met Asp Ile
His Ala Ser Asp Leu Asn Leu Leu 1295 1300 1305Thr Arg Arg Lys Leu
Ser Arg Leu Leu Asp Pro Pro Asp Pro Leu 1310 1315 1320Gly Lys Asp
Trp Cys Leu Leu Ala Met Asn Leu Gly Leu Pro Asp 1325 1330 1335Leu
Val Ala Lys Tyr Asn Thr Ser Asn Gly Ala Pro Lys Asp Phe 1340 1345
1350Leu Pro Ser Pro Leu His Ala Leu Leu Arg Glu Trp Thr Thr Tyr
1355 1360 1365Pro Glu Ser Thr Val Gly Thr Leu Met Ser Lys Leu Arg
Glu Leu 1370 1375 1380Gly Arg Arg Asp Ala Ala Asp Phe Leu Leu Lys
Ala Ser Ser Val 1385 1390 1395Phe Lys Ile Asn Leu Asp Gly Asn Gly
Gln Glu Ala Tyr Ala Ser 1400 1405 1410Ser Cys Asn Ser Gly Thr Ser
Tyr Asn Ser Ile Ser Ser Val Val 1415 1420 1425Ser Arg
14307195PRTHomo sapiens 7Met Gly Arg Ala Arg Asp Ala Ile Leu Asp
Ala Leu Glu Asn Leu Thr1 5 10 15Ala Glu Glu Leu Lys Lys Phe Lys Leu
Lys Leu Leu Ser Val Pro Leu 20 25 30Arg Glu Gly Tyr Gly Arg Ile Pro
Arg Gly Ala Leu Leu Ser Met Asp 35 40 45Ala Leu Asp Leu Thr Asp Lys
Leu Val Ser Phe Tyr Leu Glu Thr Tyr 50 55 60Gly Ala Glu Leu Thr Ala
Asn Val Leu Arg Asp Met Gly Leu Gln Glu65 70 75 80Met Ala Gly Gln
Leu Gln Ala Ala Thr His Gln Gly Ser Gly Ala Ala 85 90 95Pro Ala Gly
Ile Gln Ala Pro Pro Gln Ser Ala Ala Lys Pro Gly Leu 100 105 110His
Phe Ile Asp Gln His Arg Ala Ala Leu Ile Ala Arg Val Thr Asn 115 120
125Val Glu Trp Leu Leu Asp Ala Leu Tyr Gly Lys Val Leu Thr Asp Glu
130 135 140Gln Tyr Gln Ala Val Arg Ala Glu Pro Thr Asn Pro Ser Lys
Met Arg145 150 155 160Lys Leu Phe Ser Phe Thr Pro Ala Trp Asn Trp
Thr Cys Lys Asp Leu 165 170 175Leu Leu Gln Ala Leu Arg Glu Ser Gln
Ser Tyr Leu Val Glu Asp Leu 180 185 190Glu Arg Ser 195
* * * * *